Case of the Month
Section Editor: Nicholas Stence, MD
Children's Hospital Colorado, Aurora, CO
January 2014
Next Case of the Month coming February 4 . . .
Cisternal Tuberculomas with Infarction
- Involvement of central nervous system is one of the most serious forms of tuberculosis responsible for significant percentage of morbidity and mortality.
- Tuberculomas form a large percentage of space-occupying lesions in the brain in developing countries.
- Clinical Presentation: Fever, headache, vomiting, neck stiffness; seizures, focal neurological deficits, stupor, coma
- CSF culture for acid-fast bacilli (AFB) and CSF polymerase chain reaction (PCR) are confirmatory.
- Key Diagnostic Features: Tuberculomas may be intraparenchymal or extra-axial (subarachnoid, subdural, or epidural space). Depending on its stage of maturation, the appearance of the tuberculoma varies on MR—whether noncaseating, caseating with a solid center, or caseating with a liquid center. A noncaseating tuberculoma usually appears hyperintense on T2WI and slightly hypointense on T1WI. These granulomas show homogeneous enhancement after injection of paramagnetic contrast on T1W images. A solid caseating tuberculoma appears relatively iso- to hypointense on both T1WI and T2WI. These granulomas show rim enhancement on postcontrast T1WI. When the solid center of the caseating lesion liquefies, the center appears hyperintense with a hypointense rim on T2W images. Postcontrast T1WI demonstrates rim enhancement. Ischemic cerebral infarction resulting from the vascular occlusion is a common sequelae of tuberculous arteritis.
- DDx: Fungal granuloma, neurocysticercosis, chronic pyogenic brain abscesses
- Rx: Antituberculosis regimen: isoniazid, rifampin, ethambutol, pyrazinamide and streptomycin