Ring or disc-like enhancing lesions in partial epilepsy in India

One-hundred unselected children presenting with partial motor seizures were subjected to clinical work-up and cranial computed tomography (CT scan). Seventy-three children had an abnormal scan. On these, 56 patients had either a ring (35 patients) or a disc-like (21 patients) enhancing lesion which coincided with the probable site of origin of the seizures in all cases. The lesions were surrounded by perifocal oedema which was occasionally severe enough to produce a mass effect. The significance of these disc or ring lesions is discussed in the light of recent literature. All patients with such lesions were put on three-drug anti-tubercular therapy along with anticonvulsants. A repeat scan could be obtained in 20 patients, 10 weeks to 11/2 years after the initial scan. This showed a decrease in size or disappearance of the lesion in the majority (13 patients). Four patients showed a spot of calcification in the area of the original lesion and another two showed a typical 'target sign', i.e. calcification within a ring. It is concluded that these ring or disc lesions represent tuberculomas which are, thus, the commonest cause of partial motor seizures in children in this area.

Intracranial tuberculoma developing during therapy for tuberculous meningitis

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[Assessment of the diagnostic significance of the pleural indentation sign]

Varying manifestations of the pleural indentation sign as well as their pathologic basis were discussed. It was found that the opacity shadow standing for this kind of sign on radiograph was attributed to not only pleural indentation, but also pleural adhesion, and sometimes, lobular collapse around the lesion. Both its occurrence and morphology showed no significant difference between the lung cancer and the tuberculoma. In the light of pulmonary connective tissue theory, any lesion located at periphery of the lung and accompanied by remarkable desmoplasia and cicatricial contraction, no matter whether malignant or benign, may cause pleural shrinkage or indentation. Therefore, the pleural indentation sign does not exclusively appear in the lung cancer. It would lead us onto a wrong path if differentiation is made by overemphasizing its value. It may be radiologically helpful only in identifying the types of the lung cancer owing to its high occurrence rate in adenocarcinoma and bronchioalveolar carcinoma.

[The efficacy of X-ray signs for differential diagnosis of small lung cancer and tuberculoma. Committee for Lung Cancer Mass Screening, JATA]

In order to evaluate the efficacy of X-ray signs for the differential diagnosis of small lung cancer from tuberculoma, a cooperative study was carried out. X-ray films of 64 cases (lung cancer 35, tuberculoma 29) were read by 11 experienced chest physicians independently. The positivity of various X-ray signs were assessed respectively and obtained data were analysed with ROC analysis method. "Ill defined contour", "unevenness of density", "paleness" were proved to be relatively useful as a diagnostic tool, but "notch", "pleural indentation" were not useful in differentiating lung cancer from tuberculoma. It was also noted that great interindividual variations existed on the judgements of X-ray signs among chest specialists, and the conquest of which may be a crucial key for the universal validity of these signs.

Tuberculoma of the cerebellum--case report

A 25-year-old female presented with a 1-month history of headache and vomiting. Computed tomography revealed several enhanced nodules with surrounding edema in the right cerebellum. A T2-weighted magnetic resonance image showed heterogeneous high signal intensity throughout the right cerebellar hemisphere. A tuberculin skin test was positive and the erythrocyte sedimentation rate was slightly high, but there was no other clinical evidence of a tuberculous process. The histological diagnosis of the surgical specimen was tuberculoma. The combination of surgery and antituberculosis chemotherapy eradicated the cerebellar lesions.

[A case report of multiple intracranial tuberculoma associated with miliary tuberculosis and review of the literature]

We reported a case of multiple intracranial tuberculoma associated with miliary tuberculosis and reviewed the cases reported as intracranial tuberculoma in the past 11 years. A 41-year-old diabetic man was admitted to our hospital for the treatment of miliary tuberculosis and respiratory insufficiency. On admissIon, he had no neurological deficits except mild consciousness disturbance due to respiratory failure. He developed headache and mental confusion three weeks after the beginning of antituberculous therapy with isoniazid, streptomycin, rifampicin, and ethambutol. Neurological examination revealed that he had progressive right hemiparesis and was in a confusional state. Enhanced CT showed multiple intracranial nodular lesions. During 6 weeks, he had progressive neurological manifestations in spite of his initial antituberculous treatment. He responded well, however, to the chemotherapy with combination of isoniazid, kanamycin, pyrazinamide and ethionamide that were sensitive to tuberculous bacilli separated from his sputum. He became minimally right-hemiparetic by 6 weeks after the change of antituberculous medication. Serial enhanced CT scan proved to be of great value in the diagnosis and follow-up study of intracranial tuberculoma. From 1978 to 1988, there were 72 reported cases of intracranial tuberculoma in Japan; 37 were male, 32 were female and 3 were uncertain because of no detailed document. The age of onset was distributed from 6 month to 81 years in age and 2 peaks were seen in the second decade and fifth to seventh decade. Thirty-three (48%) out of 69 cases had multiple intracranial lesions. A few reports commented that neurological complications tended to appear even if they were under antituberculous therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated giant tuberculomata of the liver detected by computed tomography

Isolated giant tuberculomata of the liver are rare, and they are frequently misdiagnosed as primary or secondary tumors of the liver. We describe the computed tomography findings in 2 patients with giant tuberculomata of the liver. One patient had a large low-attenuation lesion with rim enhancement after contrast. The other patient had multiple calcific lesions that did not enhance but showed a rim of hypoattenuation after contrast. Biopsy established the diagnosis and both patients recovered with antituberculous chemotherapy.

[Intracranial tuberculoma, a special space-occupying process]

In four men and in one woman we found an intracranial local tuberculous infection (4 tuberculomas and 1 tuberculous abscess) in the period 1982-1988. Clinical presentation and computer tomography do not allow discrimination of intracranial tuberculomas from other space-occupying lesions. The value of the stereotactic biopsy for the diagnosis is emphasized and some characteristics of this intracranial process are discussed.

Tuberculosis of the nervous system. A clinical, radiological and pathological study of 39 consecutive cases in Riyadh, Saudi Arabia

Thirty-seven consecutive adults and 2 children with tuberculosis of the nervous system were studied. Twenty-eight patients (72%) had intracranial or intraspinal tuberculomas and only 11 patients (28%) had tuberculous meningitis. Of the 14 patients (36%) with intracranial tuberculomas 6 presented with epilepsy of late onset including convulsive status epilepticus(2). The 6 patients with multiple tuberculomas some of which were situated in the infratentorial compartment were surprisingly free of major neurological disability of systemic disturbance. Thirteen patients (33%) presented with spinal cord compression due to tuberculoma. Eight of these had associated bony abnormalities such as collapsed vertebrae and loss of pedicles usually regarded as characteristic of malignant disease and 2 presented with clinical features of acute transverse myelitis. Eleven patients (28%) had tuberculous meningitis. One of these died, 1 had a protracted illness with gait ataxia and hydrocephalus and 1 other patient was disabled by hemiplegia, dysphasia and epilepsy but the remaining 8 recovered fully. Tuberculosis outside the nervous system was found in 13 patients (33%) in 12 (31%) of whom it was pulmonary. Acid fast bacilli were demonstrated by Ziehl-Neelsen stain in 16 patients (52%) out of 31 from whom specimens were available. Mycobacterium tuberculosis was eventually cultured from only 6 specimens. These data suggest that the clinical and radiological features of tuberculosis of the nervous system in Saudi Arabia may differ substantially from those reported from other countries. In our study there was low morbidity and low fatality rate. Two patients had infratentorial tuberculomas, and 8 patients had bony abnormalities in the vertebral column, typical of malignant disease.

Tuberculous mastoiditis and laryngitis: a case report

A case of miliary tuberculosis is presented. The patient was an Asian immigrant, and presented to hospital with acute mastoiditis with apparent secondary cerebellar abscess formation. He later developed laryngeal tuberculosis, which required a tracheostomy, and a cerebral tuberculoma.

Non-surgical treatment of tuberculomas of the brain

A personal series of 14 patients with tuberculomas of the brain were treated with anti-tuberculous drugs. There were eight patients with solitary and six with multiple lesions, the size of the lesions varying from 3 x 2 cm to 7.5 x 6 cm. The symptoms and signs of tuberculomas of the brain are non-specific. The initial diagnosis is therefore presumptive and based on their characteristic CT patterns on contrast enhancement. These patterns are usually solid enhancing lesions, ring enhancing lesions or mixed solid and ring forms. The final diagnosis is established by the patient's clinical improvement and the CT scan evidence of decrease in the extent of the oedema and the size of the lesion after a therapeutic test by means of triple anti-tuberculous drug therapy lasting for 12 weeks. All patients but one were treated successfully with triple anti-tuberculous drug therapy, for a continued total period of 18 months. A failure of medical treatment occurred in one patient due to non-compliance. In this patient, the residual cerebral lesion after the tuberculoma had healed required excision to control intractable epilepsy. Associated obstructive hydrocephalus in another patient needed a ventriculo-peritoneal shunt. The patients were followed for six months to five years. There were no recurrences. It is concluded that medical treatment with anti-tuberculous drugs is the treatment of choice for tuberculomas of the brain. With the use of steroids to control the brain oedema and its resultant mass effect and increased intracranial pressure, and a ventriculo-peritoneal shunt for hydrocephalus, almost all tuberculomas of the brain, irrespective of their size, can be cured by medical treatment.

Intracranial tuberculoma in children: a new look at an old problem

Intracranial tuberculoma has become a rare cause of space-occupying intracranial lesions in childhood, but it must still be considered in the differential diagnosis. Tuberculosis remains a significant disease in developing countries and in the United States, and tuberculoma is a well known presentation of childhood tuberculosis. This diagnosis must be considered especially in persons traveling or living in developing countries and in immigrants from third-world areas. We report three cases of tuberculoma in children seen during one year at our institutions to illustrate the need for continued suspicion. We summarize the clinical presentation and current treatment recommendations and review the available literature.

CT of intracranial tuberculomas with specific reference to the "target sign"

The CT appearances of 30 patients with a total of 58 intracranial tuberculomas are discussed. Of specific interest in this study is the relatively high incidence of patients who presented with the target sign. To date there has been only 1 report of 4 cases with this appearance on CT. Four basic patterns of post contrast enhancement are described. As suggested by Welchman this study concludes that the target sign is pathognomonic of an intracranial tuberculoma.

[Cerebral tuberculoma in pregnancy]

Intracranial tuberculomas today are rare in industrialized countries. We report the case of a 29 year old female German patient who in the sixth month of her pregnancy presented with epilepsy and mild hemiparesis. Cranial CT showed a parietal contrast-enhancing lesion. Mediastinal tuberculosis was confirmed by biopsy. Both the mediastinal and the cerebral lesion together with the neurological signs resolved under therapy with antituberculous drugs, and the patient gave birth to a healthy child.

MR imaging of intracranial tuberculomas

Eight patients with intracranial tuberculomas were studied with CT and magnetic resonance (MR) imaging. Large, ring enhancing, solid lesions on CT showed low intensity on T2-weighted images and intermediate intensity on T1-weighted images. Small lesions, with ring enhancement on CT, showed central bright signal on T2-weighted images with a peripheral low intensity rim surrounded by high intensity edema. The MR imaging features of the tuberculomas were found to be distinct from those of abscesses, metastases, and gliomas.

Third ventricular tuberculoma: a case report

Tuberculomas of the brain can now be diagnosed readily with computerised axial tomography. A rare, biopsy proven case of a third ventricular tuberculoma is presented. Typical CT scan findings are discussed and management with drugs and minimal surgical intervention when necessary is stressed.

Dynamic computed tomography of cerebral parenchymal tuberculomata

The technique of intravenous dynamic cranial computed tomography has been applied to our patient population in Saudi Arabia in which parenchymal tuberculomata make up approximately 10-15% of all cerebral mass lesions. A spectrum of perfusion patterns was observed in tuberculosis progressing from presentation, through treatment, to resolution. These patterns reflect the microscopic vascular evolution of tuberculomata and parallel at least in part the effects of treatment. The method of dynamic scanning further demonstrates its value in improving the specificity of computed tomography in the evaluation of cerebral masses, thereby enhancing patient-beneficial triage.

MRI in cranial tuberculosis

A case of multiple intracranial tuberculomas is presented. CT and MRI findings are discussed and compared. MRI showed multiple tuberculomas characterised by the same signal intensity as the surrounding brain parenchyma. Differentiation could be achieved only by the perifocal oedema of high signal intensity. Changes of the lesions during chemotherapy were monitored by CT and MRI and the results are presented.

Intracranial tuberculomas: diagnosis and management

Experience with fifteen consecutive cases of intracranial tuberculomas, treated between 1981 and 1986, is summarized. Histological confirmation was obtained in twelve patients, and acid fast bacilli (AFB) were found in and cultured from the excised lesions and biopsy specimens in nine patients. Difficulties in diagnosis are discussed. A plan of management combining the operative treatment and medical therapy of the tuberculomas is outlined. The value of computerized tomography in the diagnosis and management of these patients is emphasized.

[Cerebral tuberculoma. Clinical case]

The authors report of a patients operated for a double encephalic mass in the left posterior parietal region. This lesion resulted a tubercoloma at a later investigation. This pathology is relatively common in underdeveloped countries, declining in western countries. The authors emphasize the need of a careful evaluation in searching tuberculous infection in presence of encephalic granulomatous masses.

Tuberculoma of the brain stem

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Appearance of tuberculoma during treatment of tuberculous meningitis

Case histories of two young Indian female patients are described who, during the course of regular chemotherapy for tuberculous meningitis, developed tuberculoma as suggested by CT-scan. Such lesions were not seen at the start of treatment. Twelve similar cases are collected from literature. Most of the patients developed new symptoms and/or signs having initially shown good response to drugs. The pathogenetic mechanisms for such an evolution of lesions are not known but possibly include immunological modulations. This development should not lead to excessive anxiety for treating physician. Surgery is not needed and a patient follow up is well rewarded. Pyrazinamide has emerged as a useful drug.

Computed tomography of cerebral tuberculoma

The CT findings in nine cases of cerebral tuberculoma are illustrated. Larger tuberculomas frequently show a ring-like enhancement after contrast medium infusion, whereas the smaller lesions display a more homogeneous enhancement. The tuberculoma's course toward regression and complete disappearance during conservative management can be followed by CT.

Symptomatic intracranial tuberculoma developing during treatment of tuberculosis: a report of 10 patients and review of the literature

Ten patients with intracranial tuberculomata which developed during treatment for tuberculosis are described. The initial infection was meningeal in five, miliary in three and pulmonary in two and all improved after treatment was started. However 10 days to five months (mean two months) after the start of treatment, new neurological symptoms and/or signs occurred that led to the recognition of intracranial tuberculomata. CT brain scans suggested tuberculomata in all 10 patients; there were several lesions in five and histological confirmation was obtained in three cases. Earlier CT brain scans (six weeks to five months before) were carried out in five patients and in none was a tuberculoma seen. After treatment with anti-tuberculous drugs and control of raised intracranial pressure when present, five patients made a full recovery, three were left with mild neurological deficit and in two it is too early to assess the outcome.

Intracranial tuberculosis due to Mycobacterium bovis

A case of intracranial tuberculosis due to Mycobacterium bovis is presented. Computed tomography (CT) identified multiple enhancing lesions which by biopsy proved to be intracranial tuberculomas. The CT appearance, epidemiology and bacteriology as well as pharmacotherapy of this uncommon entity are discussed.

In vivo tuberculoma creation and its radioimmunoimaging

Since tubercular lesions form an important differential diagnosis in our country, tuberculoma models in mice have been created and imaged using iodine-125 radiolabelled antimycobacterial monoclonal antibodies for the aetiopathological diagnosis.

Intraventricular tuberculoma. Report of four cases in children

Four cases of intraventricular tuberculoma (IVT) in children are here reported. In none of the patients was there clinical evidence pointing to the intraventricular location. CT scan findings comprised three stages of development, namely: immature, mature and old. Ependymal attachment and asymmetric hydrocephalus were present in three cases, meningitis in two and ependymitis in one. Septum pellucidum traction was clearly observed in two patients, strongly supporting an adhesive process characteristic of intraventricular tuberculosis. Following specific treatment, the tuberculomas remitted partially or entirely.

Tuberculous meningitis: role of CT in management and prognosis

Serial computed tomographic scans were performed during the course of tuberculous meningitis in 25 patients aged 1-70 years. Hydrocephalus rarely occurred without other abnormalities. Marked ventricular enlargement was associated with extensive basal enhancement. Basal meningeal enhancement was not a good indicator of the clinical state although marked enhancement was a risk factor for the development of basal ganglia infarction. Infarcts were much more common in children than in adults and were sometimes asymptomatic. Radiological abnormalities sometimes developed during treatment and often did not resolve completely. Many patients had severe residual neurological problems.

Intracranial tuberculoma in a Sudanese child: response to medical treatment

We report a 4-year-old girl in whom a probable intracranial tuberculoma was diagnosed by carotid angiography. The child's clinical picture improved and the tuberculoma certainly considerably reduced in size as shown by a follow-up angiogram 20 months after institution of antituberculous treatment. Our case adds one to those in whom medical treatment was a success. Surgery should be reserved for medical failures and where diagnosis is uncertain.

CNS tuberculosis

Tuberculous meningitis is a rare, treatable neurologic disorder, in which early recognition is paramount because outcome depends greatly on the speed with which therapy is initiated. Patients with meningitis and CSF findings of low glucose, elevated protein and pleocytosis with evidence of tuberculosis elsewhere in the body (chest radiographs, positive tuberculin skin test), or a history of exposure to tuberculosis should be treated immediately with antituberculous medication. When the diagnosis remains uncertain, serial examination of the CSF for tuberculous organisms will often yield positive results. The CT scan may show hydrocephalus, a basilar arachnoiditis, or intraparenchymal lesions: tuberculomas. Hydrocephalus may respond to early shunting. Tuberculomas are best treated medically. Therapy should include INH and rifampin; ethambutol and pyrazinamide are suggested for the first 2 months of therapy. Steroids may be useful in diminishing the inflammatory response when altered consciousness or focal neurologic signs are present.

Central nervous system tuberculosis with the acquired immunodeficiency syndrome and its related complex

Central nervous system tuberculosis occurred in three patients with the acquired immunodeficiency syndrome (AIDS) and seven patients with AIDS-related complex who were evaluated for 48 months. Nine patients were intravenous drug abusers and one was Haitian. Five patients had cerebral-ring-enhancing lesions and three had hypodense areas. The clinical spectrum included meningitis in two patients, multiple cerebral abscesses in one, and tuberculomas in four. All Mycobacterium tuberculosis isolates were sensitive to standard antituberculous drugs. All patients received treatment with isoniazid, rifampin, and pyrazinamide; six patients also received streptomycin. Three patients with AIDS died of opportunistic infection preceded by central nervous system tuberculosis. Among the patients with the AIDS-related complex, three improved with treatment, three were lost to follow-up, and one died. Tuberculosis should be considered in the differential diagnosis of central nervous system mass lesions in intravenous drug abusers with AIDS or AIDS-related complex. Because patients with tuberculosis can be cured, biopsy of accessible brain mass lesions should be mandatory. Preventive therapy may be indicated in drug abusers without disease.