Surgery for brain tuberculosis: a review.

The two main manifestations of brain tuberculosis that require surgery are hydrocephalus associated with tuberculous meningitis (TBMH) and brain tuberculomas. TBMH most often responds to medical therapy but surgery is required promptly for those who fail medical therapy. Both ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are valid options although the latter is more often successful in patients with chronic hydrocephalus than in those with acute meningitis. Patients with TBMH are more prone to complications following VP shunt than other patients. The outcome of these patients is determined by the Vellore grade (I to IV) of the patients prior to surgery with those in good grades (I and II) having a better outcome and those in the worst grade (IV) having a high mortality in excess of 80 %. Patients with brain tuberculomas present clinically with features of a brain mass, indistinguishable clinically from other pathologies. CT and MR features might provide a probable diagnosis of a tuberculoma but most often a histological diagnosis is desirable. Empiric medical therapy is reserved for a small number of patients. Although the treatment of brain tuberculomas is essentially medical, surgery is required when the diagnosis is in doubt, to reduce raised intracranial pressure or local mass effect and to obtain tissue for culture and sensitivity studies. Stereotactic biopsy, stereotactic craniotomy and excision of superficial small tuberculomas and microsurgery are all procedures used to manage brain tuberculomas. The outcome in patients with brain tuberculomas is good if the tuberculous bacillus is sensitive to the anti-tuberculous therapy. The duration of therapy is debated but we suggest at least 18 months of combination therapy with three or four anti-tuberculous drugs and continue the therapy till the tuberculoma has resolved on neuro-imaging.

Orbital cortical approach to lesions around the frontal horn of the lateral ventricle: indication and surgical parameters.

BACKGROUND: An orbital cortical approach to lesions in the region of the frontal horn is described on the basis of surgical experience with five cases and dissections of three cadaveric brain specimens. The approach involves cortical incision over the orbital surface of the frontal brain and directing the surgical trajectory superiorly. The possible indications of the approach and the critical surgical parameters are described. METHOD: To assess the landmarks that could be used to employ the approach, three formalin-fixed frozen cadaveric brains were appropriately dissected. A number of parameters were analysed to identify the safe entry points and the trajectory to approach the frontal horn. Five lesions located in the region of the frontal horn were operated upon by employing the discussed approach. RESULTS: The frontal horn is located at the depth of approximately 18 mm (range, 17-20 mm) from the orbital surface of the frontal brain. In a lateral perspective, the tip of the frontal horn is in line with the tip of the temporal pole. Wide opening of the Sylvian fissure, relaxation of the brain and lateral basal frontal exposure can be used effectively to obtain a suitable angulation for conduct of surgery. Avoidance of olfactory tracts and Heubner's perforating artery at the site of medial orbital gyrus cortical incision and appropriately directing the corticectomy that avoids the association fibre tracts, caudate head and internal capsule can lead to a safe exposure of the frontal horn. The approach is suitable for lesions involving or in the vicinity of the inferior aspect of the frontal horn and in the region of the caudate head. Neuronavigation can be of assistance during surgery and avoid critical misdirection. All the five lesions were treated without consequence. CONCLUSIONS: For selected indications, an inferior frontal or orbital cortical approach can be used effectively and safely to approach lesions in relation to the frontal horn. The approach needs to be precise to avoid injury to vital adjoining structures.

Large pontine tubercular abscess treated surgically.

Tuberculosis of the central nervous system (CNS) is a life threatening condition with 50% mortality in advanced disease and serious neurological deficits in those who survive. Tuberculous abscess is a rare manifestation of CNS tuberculosis, brainstem involvement being even rarer. The management of these conditions poses a great challenge to the treating physician. We report a case of large tubercular abscess of pons which increased in size on anti-tubercular treatment, but showed excellent improvement following craniotomy and aspiration.

Ruptured intracranial tubercular infectious aneurysm secondary to a tuberculoma and its endovascular management.

Tuberculosis remains to be an endemic infectious disease in developing countries. With the increasing incidence of HIV and AIDS, there is further increase in the incidence of tuberculosis. Although CNS involvement by tuberculosis is seen in all age groups, there is a predilection for younger patients. Central nervous system tuberculosis may present as tuberculoma, cerebral abscess or tuberculous meningitis (TBM). Vasculitis secondary to TBM can cause infarcts and rarely aneurysm formation. In TBM there is a thick, gelatinous exudate around the sylvian fissures, basal cisterns. There is a border zone reaction occurring in the surrounding brain tissue. Inflammatory changes occur in the vessel wall of the arteries bathed in the exudate leading to narrowing of the lumen or occlusion by thrombus formation. The vessels at the base of the brain are most severely affected, including the internal carotid artery, proximal middle cerebral artery and perforating vessels of the basal ganglion. In these cases, the infection probably spreads from the adventitia towards the internal elastic lamina, weakening the vessel wall, with subsequent formation of an infectious aneurysm. Intracranial tuberculomas are space-occupying masses of granulomatous tissue that result from haematogenous spread from a distant focus of tuberculous infection. In endemic regions, tuberculomas account for as many as 50% of all intracranial space-occupying lesions. Inflammation in the vessels surrounding the tuberculoma may lead to formation of aneurysms. This case report illustrates an unusual case of intracranial tuberculomas complicated by intralesional haemorrhage due to an infective tubercular aneurysm in its vicinity. The endovascular treatment of these infectious aneurysms is safe, effective and durable. To the best of our knowledge, this is the first case report of a tuberculoma having intracranial haemorrhage on anti-tubercular treatment due to an infectious aneurysm developing in an artery in the vicinity of the tuberculoma and managed end.

[The effect of surgical treatment of tuberculous abscesses and tuberculoma of the brain on the dynamics of neurological symptoms]. / Vliyanie khirurgicheskogo lecheniya tuberkuleznykh abstsessov i tuberkulem golovnogo mozga na dinamiku nevrologicheskoi simptomatiki.

OBJECTIVE: To evaluate the efficacy of surgery in reducing neurological symptoms in patients with focal brain tuberculosis. MATERIAL AND METHODS: Seventy-four patients with tuberculosis meningoencephalitis were studied. Among them, 20 people with a life expectancy of at least 6 months were identified, in whom foci with a ring-shaped accumulation of contrast along the periphery were determined during MSCT of the brain. Formed tuberculomas and abscesses were removed from 7 patients (group 1) under neuronavigation control. Indications for the operation were: the absence of a reduction in size for 3-4 months, the limitation of the lesion to 1-2 foci with reduction of perifocal edema according to MSCT and normalization of cerebrospinal fluid. Six patients had contraindications or refusals from operations (group 2). In 7 patients, there was a decrease in formations by the control period (group 3). Neurological symptoms in the groups at the beginning of the observation were similar. The duration of observation was 6-8 months. RESULTS: In group 1, patients were discharged with improvement, postoperative cysts were determined in all of them at discharge. In group 2, 67% died. In group 3, 43% of patients had a complete reduction of foci during conservative treatment, in 57% cysts formed in place of foci. Neurological symptoms decreased in all groups, with the most decrease in group 1. However, statistical analysis did not show significant differences between the groups regarding the reduction of neurological symptoms. A significant difference in the mortality criterion between groups 1 and 2 was obtained. CONCLUSION: Despite the absence of a significant effect on the reduction of neurological symptoms, the high survival rate of operated patients shows the need to remove tuberculosis formations in all the cases.

Intracranial giant tuberculoma: A 7-year institutional experience and literature review.

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.

Cerebral tuberculoma presented as primary malignant brain tumor: a case report.

A 62 year-old Thai man presented symptoms of chronic progressive headache for nearly one year and left side ataxia for two weeks. MRI brain suggested a primary malignant brain tumor with moderate hydrocephalus. Total removal of the lesion was performed. The histopathological report was caseating granulomatous inflammation involving cerebellar parenchyma; suggestive of tuberculoma, PCR for M. Tuberculosis complex, using brain tissue from formalin-fixed paraffin-embeded block, yields positive result for M. Tuberculosis complex. He was treated with antituberculous drugs.

Isolated sellar tuberculoma presenting with panhypopituitarism: clinical, diagnostic considerations and literature review.

Tuberculosis, a common cause for chronic intracranial infections can mimic varied intracranial pathologies including tumours. Pituitary tuberculomas are rare lesions and are often diagnosed pre-operatively as pituitary tumours. We report a case of a 31-year-old lady with a sellar-suprasellar lesion who presented with panhypopituitarism. The patient underwent a trans-nasal, trans-sphenoidal surgical decompression of the lesion. Histopathology revealed a tuberculous lesion in the pituitary. The characteristic radiological features of sellar tuberculomas are discussed along with a review of literature. Atypical sellar radiology in the presence of a thickened pituitary stalk could point to pathology other than pituitary adenoma, possibly a chronic inflammatory condition like tuberculoma.

Ruptured intraventricular tuberculous brain abscess mimicking cystic neoplasm: a case report.

Central nervous system (CNS) tuberculosis is a potentially life-threatening condition that may manifest in different forms and simulate other pathologies. It rarely involves the ventricles and the occurrence of primary intraventricular tuberculous brain abscess (TBA) has exceptionally been reported. As far as we know, ruptured intraventricular TBA has not been described before. An immunocompetent 56-years-old man was admitted for sub-acute intracranial hypertension with behaviour disorders. Cranial magnetic resonance imaging (MRI) showed a cystic lesion of the third ventricle containing fluid-fluid level with biventricular hydrocephalus and debris in the occipital horns. A ruptured cystic neoplasm was first considered. The patient underwent surgery via a right transcortical transventricular approach, combining both microscope and endoscope. The puncture of the lesion brought pus and the Ziehl-Neelson (ZN) staining demonstrated acid-fast bacilli. Intraventricular tuberculous abscess is an extremely rare condition that can take an unusual radiological appearance. This observation highlights the consideration of tuberculosis within the list of differential diagnosis of intraventricular cystic lesions in immunocompetent hosts.

Diagnostic and therapeutic role of CT-guided stereotactic surgery in the management of intracranial tuberculomas.

AIM: CT-guided stereotactic methods have long been used for the diagnosis and treatment of intracranial masses. Intracranial tuberculoma is a rare form of extrapulmonary tuberculosis. Histological confirmation is the gold standard for a correct diagnosis. However, histopathological diagnosis and excision of these lesions have advantages over open surgical methods. This study presents our experience on the use of stereotactic biopsy and excision in the management of intracranial tuberculomas. MATERIAL AND METHODS: Thirteen patients with intracranial masses underwent stereotactic procedures for tissue samples to establish histopathological diagnosis. In 6 suitable patients, stereotactic microsurgical excision was performed for both diagnostic and therapeutic purposes, whereas only stereotactic biopsy was conducted in the remaining subjects. RESULTS: The tuberculoma diagnosis was established in 12 out of 13 cases (92%). Seizure control was achieved in all patients admitted with a history of seizures. There was no procedure-related mortality, none of the patients suffered permanent disability and most procedures were uneventful. Total resection without any residual mass was done. All patients responded to antituberculous treatment with complete lesion disappearance. CONCLUSION: These findings suggest that CT-guided stereotactic surgery of intracranial tuberculomas has advantages over other methods, with a potential to become the first-line modality, particularly as a diagnostic tool, in the management of these lesions.

Cerebral Tuberculoma of Right Frontal Lobe in an Unconscious Patient.

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.

Role of Surgery in Intracranial Tuberculomas and Proposal of a Novel Diagnostic Criteria for Diagnosis (Sri Venkateswara Institute of Medical Sciences Criteria).

OBJECTIVE: Intracranial tuberculomas (IT) are often misdiagnosed or overdiagnosed, resulting either in delay in treatment of this curable illness or in unnecessary surgical intervention. A new method of diagnostic criteria for preoperative diagnosis of IT is proposed. METHODS: A retrospective analysis was performed of all patients with a preoperatively suspected diagnosis of IT who were operated on at our institute from 2010 to 2019. The patients were divided into 2 groups: biopsy-proven IT and biopsy ruled out IT. Tests of diagnostic accuracy were applied for each finding. RESULTS: A total of 69 patients were operated on in the given period, 40 of whom were proved by biopsy as having tuberculoma. In the remaining 29 patients, the biopsy ruled out tuberculoma. Three features were identified as major criteria and 7 features were identified as minor criteria. We suggest that the diagnosis of IT should be made preoperatively, in the presence of 3 major criteria, 2 major and 3 minor criteria, 1 major and 5 minor criteria, or 7 minor criteria. By applying these diagnostic criteria to each of the 69 patients, we could diagnose IT in all 40 patients and exclude IT in all 29 patients preoperatively. CONCLUSIONS: We suggest that empirical antituberculous treatment should be started in a patient without the need for invasive surgery if our criteria are met. If the criteria are not met, we suggest further evaluation of the patient for an alternative diagnosis or early surgery for definitive management. Surgery decreases the duration of antituberculous treatment and helps in early resolution of lesions.

Tuberculous temporal brain abscess mimicking otogenic pyogenic abscess.

Tuberculous brain abscess is a rare manifestation of central nervous system tuberculosis. We report the case of a tuberculous temporal lobe abscess in a 14-year-old female child that mimicked an otogenic pyogenic brain abscess. The patient had no prior history of tuberculosis. She had chronic otitis media and presented with signs of raised intracranial tension. Radiological imaging was suggestive of an acute pyogenic left temporal lobe abscess. A left temporal craniotomy was performed and the abscess was completely excised. Histological examination was consistent with a chronic abscess, and bacterial cultures were negative. A left radical mastoidectomy was also carried out. However, she presented with repeated abscess formation at the same site over the next 8 weeks, which was refractory to surgical therapy and broad-spectrum antibiotic administration. Furthermore, the purulent exudate showed strong positivity in the PCR test for tubercular bacilli. After administration of antituberculous treatment, she showed gradual clinical and radiological improvement. At follow-up after 2 years, she is asymptomatic. CT imaging at 2 years showed total resolution of abscess. Tuberculous abscess in the temporal lobe following otogenic infection has not been reported in the pediatric population. Although rare, the possibility of tuberculous etiology should be borne in mind as a differential diagnosis of acute abscess of otogenic origin, especially in endemic areas where the incidence of chronic otitis media as well as tuberculosis is high. The pathogenesis and treatment of tuberculous brain abscess in children is reviewed in light of the current literature on the subject.

Cerebellar tuberculoma presenting as haematoma--a case report and pathophysiological consideration.

Intracranial tuberculoma represents the most common mass lesion in neurotuberculosis. We report an unusual case of tuberculoma with haemorrhage presenting clinically as a cerebellar haemorrhage. Cranial CT scan revealed a peripherally enhancing cerebellar mass with haemorrhage and obstructive hydrocephalus, requiring urgent surgical evacuation of the haematoma. Histopathological examination revealed tuberculoma with features of phlebitis. In view of the pathological evidence of phlebitis in the lesion, it could represent an immune-mediated acute haemorrhagic leucoencephalitis in response to tubercular antigens.

Factors Predicting the Need for Prolonged (>24 Months) Antituberculous Treatment in Patients with Brain Tuberculomas.

BACKGROUND: Patients with brain tuberculomas are generally managed with 12-18 months of antituberculous treatment (ATT) with or without surgery. However, a subset of these patients may require ATT for longer periods. We studied the factors that were associated with the need for prolonged ATT (>24 months) in patients with brain tuberculomas. METHODS: This retrospective study included patients with intracranial tuberculomas managed from January 2000 to December 2015 if they were followed up until completion of therapy and resolution of the tuberculoma/s. The predictive factors analyzed were the number of lesions (solitary vs. multiple), location (infratentorial vs. supratentorial and infratentorial), previous ATT treatment (yes vs. no), surgery (yes vs. no), and size of the lesion (≤2.5 cm vs. >2.5 cm). RESULTS: Of the 86 patients, 19 (22%) received ATT for >2 years. On multivariate analysis, multiple lesions were significantly associated with the need for prolonged ATT (P = 0.02). Size of the tuberculoma showed a trend toward significance (P = 0.06), with tuberculomas >2.5cm having a 3.68 times increased risk of requiring prolonged ATT. CONCLUSIONS: Although 78% of brain tuberculomas resolve with 12-24 months of ATT, 22% required >24 months of ATT. Multiple tuberculomas had significant association with prolonged ATT, with a median duration of resolution of 36 months. Because tuberculomas >2.5 cm were likely to need longer duration of ATT, brain tuberculomas that require surgery should be excised totally or reduced in size to <2.5 cm to enable early resolution.

Intracranial tuberculoma with adjacent inflammatory aneurysms.

We describe for the first time a case of intracranial tuberculoma with adjacent intracerebral inflammatory aneurysms, and include a brief discussion of the developmental mechanism of these pathologies. A 28-year-old woman presented with a history of intermittent seizure attacks. She had been diagnosed as having pulmonary tuberculosis 1 year previously, and had been treated with antituberculosis medications for 9 months. Her brain MRI revealed a 1-cm-diameter round subcortical mass lesion on the left parietal lobe, which showed gadolinium enhancement. At surgery, we were surprised to find multiple small aneurysms in the distal middle cerebral arteries surrounding the mass. The mass was totally removed, and the aneurysms were secured by wrapping and fibrin tissue adhesive. The mass was diagnosed as a tuberculoma, and the aneurysms were suspected of being inflammatory in nature and associated with the patient's tuberculosis.

Meckel's cave tuberculoma with unusual infratemporal extension.

The authors describe a rare case of intracranial tuberculoma of the Meckel's cave and cavernous sinus with extension into the infratemporal fossa causing widening of the foramen ovale and adjacent bone destruction. The rarity of the lesion and the unusual extension of the lesion are presented with a brief review of literature.