Intracisternal tuberculoma: a refractory type of tuberculoma indicating surgical intervention.

BACKGROUND: Central nervous system (CNS) tuberculoma is a rare disease with severe neurological deficits. This retrospective research is to review the data of patients diagnosed as CNS tuberculoma. Surgeries were performed in all patients. The clinical features especially the neurological image and the anatomical characters of the tuberculomas were concerned. METHODS: Totally 11 patients diagnosed as CNS tuberculoma were admitted in Guangzhou First People's Hospital (7cases) and Changzheng Hospital (4 cases) during 2006-2015. The data including preoperative condition, neurological imaging, and surgical findings was collected and analyzed. RESULTS: The lesions of nine patients (9/11) were totally or subtotally excised and two (2/11) were partially excised. Neurological functions of all patients were improved after surgery without secondary infection. Lesions of nine (9/11) patients preoperatively progressed as a result of paradoxical reaction. Of the 9 patients demonstrated paradoxical progression, all lesions were partially or totally located at the cisterns or the subarachnoid space. Preoperative ATTs lasted 2 to 12 months and tuberculomas were not eliminated. The arachnoid was found thickened and tightly adhered to the lesions during surgeries. Of the 2 cases that paradoxical reaction were excluded, both patients (case 6, intramedullary tuberculoma; case 11, intradural extramedullary tuberculoma) were admitted at onset of the disease. ATTs were preoperatively given for 1 week as neurological deficits aggravated. The tuberculous lesions of CNS or other system showed no obvious change and paradoxical reaction could not be established in both cases. CONCLUSIONS: Exudates of tuberculosis is usually accumulated in the cisterns and frequently results in the paradoxical formation of tuberculoma. Intracisternal tuberculoma is closely related to paradoxical reaction and refractory to anti-tuberculosis therapy. Micro-surgical excision is safe and effective. Early surgical intervention may be considered in the diagnosis of intracisternal tuberculoma especially when paradoxical reaction participates in the development of tuberculoma.

Pre-operative declining proportion of fractional anisotropy of trigeminal nerve is correlated with the outcome of micro-vascular decompression surgery.

BACKGROUND: Type 2 trigeminal neuralgia (TN) is an intractable neuropathic pain syndrome compared with type 1 TN because of the difficulty of diagnosis as well as the unsatisfactory prognosis. Neurovascular compression (NVC) is considered the major pathology of TN. Routine magnetic resonance imaging (MRI) sequences are inadequate for revealing the effect of NVC which is related to the surgical decision and outcome. The decreasing of fractional anisotropy (FA), one of the MRI diffusion tensor imaging (DTI) metrics, is correlated with the demyelination of trigeminal nerve (TGN) that reveal the severity of NVC. METHODS: A retrospective review of patients treated with micro-vascular decompression (MVD) surgery was undertaken. All the patients were diagnosed as type 2 TN. FA of TGN of both sides were measured. The FA declining proportion = ((the mean FA value of healthy lateral)-(the mean FA value of the symptomatic lateral))/(the mean FA value of healthy lateral). Declining proportion of FA value, discovery of surgery and outcome of MVD were recorded and analyzed. Logistic regression analysis and linear regression analysis were employed to analyze the risk factors of declining proportion of FA value and MVD outcome. RESULTS: Nineteen patients were assessed in our study. The average declining proportion of FA value for all patients was 0.25 ± 0.12. The average declining proportion of FA value of "success" and "failure" group was 0.32 ± 0.09 to 0.14 ± 0.10 (P = 0.002 < 0.05). The declining proportion of FA value of artery (including the artery plus vein situation) was 0.34 ± 0.06 in contrast to 0.15 ± 0.08 of vein (P = 0.000 < 0.05). MVD outcome was correlated with declining proportion of FA value (AUC = 0.900). Furthermore, declining proportion of FA value was higher in arterial compression situation. CONCLUSION: FA value quantitatively showed the alteration of TGN caused by NVC. It provided direct evidence about the effect of NVC which facilitated the diagnosis and surgical decision of type 2 TN. Besides, significant reduction of FA value may predict an optimistic outcome of MVD.