Evaluation of cerebral arterial and venous system in tuberculous meningitis

Intracranial manifestations of central nervous system tuberculosis in children

Tuberculosis remains a significant global health challenge, with central nervous system tuberculosis (CNS-TB) posing a substantial threat, accounting for 1-10% of all tuberculosis cases. This article explores the diverse manifestations of CNS-TB in children, with a particular focus on tuberculous meningitis and tuberculomas, as well as their associated complications. Diagnostic imaging, including CT and MRI, plays a crucial role in the early detection of CNS-TB. The article emphasizes the pivotal role of imaging in the diagnosis and management of these manifestations, underscoring the importance of early recognition by healthcare professionals. Ultimately, raising awareness among pediatric radiologists, pediatricians, and pediatric neurologists is crucial for prompt intervention and improved outcomes in cases of CNS-TB.

Concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated with miliary tuberculosis

Cerebrovascular complications of central nervous system tuberculosis (TB) are predictors of poor prognosis and adverse outcomes. These complications are mainly intracranial arterial involvement, with occasional venous involvement. Here, we present a 67-year-old woman with concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated by miliary tuberculosis. Mycobacterium tuberculosis was observed on the luminal side of the carotid plaques in pathological specimens. Treatment with anti-TB drugs alone would likely not cure the patient, as M. tuberculosis would continue to disseminate. Endarterectomy could directly remove the embolic source, and a complete cure was achieved.

Global Frequency and Clinical Features of Stroke in Patients With Tuberculous Meningitis: A Systematic Review

IMPORTANCE

Stroke in tuberculous meningitis (TBM) is associated with significant morbidity and mortality.

OBJECTIVE

To determine the country-specific, regional, and overall prevalence of stroke among patients with TBM, including their clinical manifestations, stroke locations, and outcomes.

EVIDENCE REVIEW

This systematic review searched records in MEDLINE by PubMed, Scopus, and EMBASE until July 2020 for relevant articles on the occurrence and characteristics of stroke in TBM. Randomized clinical trials and cohort studies that included a population of patients with TBM were analyzed for clinical manifestations, type of stroke, area of stroke, vascular territory, and outcomes. Studies that did not report the occurrence of stroke, reported as abstract only with no full-texts available, and articles not in English were excluded. The country-specific, regional, and overall frequencies of stroke among patients with TBM were determined; secondary analysis enumerated the summary estimates of the clinical presentations, common locations of stroke, and outcomes. The Murad tool was used to assess methodological quality.

FINDINGS

From 852 articles identified, 71 studies involving 2194 patients with stroke in TBM were included. The sample size for each study ranged from 17 to 806 patients. The frequency of stroke in TBM showed an estimate of 0.30 (95% CI, 0.26-0.33). The most common clinical manifestations were fever and headache. The lateral striate, middle cerebral, and medial striate arteries were typically affected. The basal ganglia, cortex and lobar, and internal capsule were the frequently involved areas of the brain. The pooled proportions of mortality and poor outcomes were 0.22 (95% CI, 0.16-0.29) and 0.51 (95% CI, 0.37-0.66), respectively.

CONCLUSIONS AND RELEVANCE

The results of this systematic review suggest that stroke is considerably frequent among patients with TBM. The reported frequencies of stroke in TBM and its clinical features vary across the studies and populations.

Vascular Manifestations of Tuberculous Meningitis: MR Angiography and Venography Study

Purpose  The purpose of this study is to evaluate magnetic resonance (MR) angiography (MRA) and venography (MRV) findings in tuberculous meningitis (TBM).

Methods  Thirty consecutive patients of clinically diagnosed TBM were enrolled. Apart from T2-weighted imaging, T1-weighted imaging (T1WI), diffusion-weighted imaging, susceptibility-weighted imaging, fluid-attenuated inversion recovery, and postcontrast T1WI, time-of-flight (TOF) MRA and postcontrast MRV were done in all the patients. MRV was done after intravenous administration of gadolinium-based contrast agent followed by postcontrast T1WI. MRA and MRV findings were analyzed.

Results  Mean age of the patients was 33.13 ± 14.93 years. Duration of symptom was 34.90 ± 33.82 (range: 10–150) days. Out of 30 patients, 11 were categorized as definite TBM and 19 probable TBM. Eighteen (60%) were grade I, 7 (23%) grade II, and 5 (16%) grade III TBM based on severity. MR abnormalities were in varying combinations of leptomeningeal enhancement in 24 (80%), pachymeningeal in 2, both in 3, tuberculomas in 13 (43.3%), ventriculitis in 1, hydrocephalus in 16 (53.3%), and infarcts in 10 (33.3%) patients out of which the tubercular zone infarct in 9 patients. TOF MRA showed arterial abnormality in 13 patients. Anterior cerebral artery and middle cerebral artery have commonly involved vessels. Dural sinus thrombosis was noted in two patients. Both were female. One patient had subacute thrombus in the posterior part of superior sagittal sinus, left transverse sinus, and proximal right transverse sinus. The second patient had a filling defect in the transverse sinus.

Conclusion  In TBM, there is predominant arterial involvement causing infarcts which are usually seen in the tubercular zone. However, occasionally, there may be venous involvement causing cerebral venous sinus thrombosis.

Challenges in the diagnosis of tuberculous meningitis

Tuberculosis (TB) continues to pose a significant public health problem. Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary TB. TBM carries a high mortality rate, including for those receiving treatment for TB. Diagnosis of TBM is difficult for clinicians as it can clinically present similarly to other forms of meningitis. The difficulty in diagnosis often leads to a delay in treatment and subsequent mortality. Those who survive are left with long-term sequelae leading to lifelong disability. The microbiologic diagnosis of TBM requires the isolation of Mycobacterium tuberculosis from the cerebrospinal fluid (CSF) of an infected patient. The diagnosis of tuberculous meningitis continues to be challenging for clinicians. Unfortunately, many cases of TBM cannot be confirmed based on clinical and imaging findings as the clinical findings are nonspecific, while laboratory techniques are largely insensitive or slow. Until recently, the lack of accessible and timely tests has contributed to a delay in diagnosis and subsequent morbidity and mortality for many patients, particularly those in resourcelimited settings. The availability of Xpert Ultra and point-of-care lipoarabinomannan (LAM) testing could represent a new era of prompt diagnosis and early treatment of tuberculous meningitis. However, clinicians must be cautious when ruling out TBM with Xpert Ultra due to its low negative predictive value. Due to the limitations of current diagnostics, clinicians should utilize a combination of diagnostic modalities in order to prevent morbidity in patients with TBM.

Cerebrovascular complications in tuberculous meningitis-A magnetic resonance imaging study in 90 patients from a tertiary care hospital

BACKGROUND

Cerebrovascular complications of tuberculous meningitis (TBM) are associated with increased morbidity and mortality. We retrospectively reviewed clinicoradiological findings of 90 TBM patients who presented to a tertiary care hospital, with emphasis on frequency and distribution of infarcts on diffusion imaging and pattern of vascular involvement on magnetic resonance (MR) angiography (MRA).

MATERIALS AND METHODS

MR images of 90 TBM patients at presentation (2012-2018) were coanalyzed by two radiologists for tuberculomas, leptomeningeal enhancement (LM), hydrocephalus, infarct and vascular abnormalities. Infarcts were categorized based on location ("tubercular" (TB) or "ischemic" zones) and arterial supply (perforators and cortical branches). Clinical and laboratory findings were correlated with imaging data.

RESULTS

Ninety TBM patients (age 10-82 years) were enlisted after application of inclusion criteria. Tuberculomas were most common (100%) followed by LM (84.4%), cerebral infarcts (57.7%) and hydrocephalus (29%). Location-wise, 35% infarcts were in ischemic, 13% in TB and 15% in both zones. According to arterial supply, infarcts equally (50%) involved perforators from the lateral lenticulostriate and posterior cerebral (PCA)/basilar artery (BA) followed by medial lenticulostriate arteries (23%). MRA was available in 74.4% and abnormal in 43.2%. The middle cerebral artery was frequently involved (76%) followed by the anterior cerebral artery (38%), internal carotid artery (31%), PCA and BA. Six had diffuse narrowing with a paucity of distal vessels. Cerebral infarction was associated with hydrocephalus (p = .0019) and vasculitis (p < .001).

CONCLUSION

In TBM, strokes are common and mainly involve the perforators and cortical branches. MR is the imaging modality of choice for early diagnosis and timely management.

Advances in the Diagnosis and Management of Tubercular Meningitis in Children

Tubercular meningitis (TBM) continues to be a common cause of neuromorbidity in children. There is no single diagnostic method that can rapidly detect Mycobacterium tuberculosis (M.tb) in TBM patients with high sensitivity and specificity. Newer diagnostic modalities like Xpert/RIF assay and Loop mediated isothermal amplification assay (LAMP) have gained an essential stand in molecular diagnostics due to their high specificity, modest sensitivity in cerebrospinal fluid (CSF) and quick availability of results. Intensified drug regimens using high dose rifampicin, fluoroquinolone and aspirin appear to be useful adjunct therapy but more pediatric clinical trials on large scale are needed to determine their appropriate place in pediatric TBM. The emergence of multi and extreme drug resistant M.tb strains further challenges the standard therapy. In this review authors summarize challenges of the currently used diagnostic methods and treatment for TBM and discuss the recent advances.

Ischemic stroke and infectious diseases in low-income and middle-income countries

PURPOSE OF REVIEW

To address the important relationships between stroke and infection, focusing on the most frequent infections found in low-income and middle-income countries.

RECENT FINDINGS

Stroke is one of the leading causes of mortality and disability worldwide, with a great proportion of the stroke burden occurring in low-income and middle-income countries. Infectious diseases are still a great health problem in developing countries and it is possible that the proportion of infection-related strokes is greater in these nations. Infectious diseases and stroke have a bidirectional relationship. Common infections may act as risk factors and can trigger stroke through different mechanisms in their acute phase. Several intracranial and systemic infections can cause stroke as a direct complication, such as Chagas disease, neurosyphilis, tuberculous meningitis, and neurocysticercosis. These conditions are of particular interest to low-income and middle-income countries, but also relevant to high-income nations because of increasing migration. Finally, infection is a frequent poststroke complication, with great impact in the patient outcome.

SUMMARY

Infectious diseases and stroke are common problems in low-income and middle-income countries. More studies are necessary to fully elucidate the real impact of infectious diseases on stroke burden, especially in countries where epidemiological data are still scarce.

The neurocritical care of tuberculous meningitis

Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.

A Child with Tuberculous Meningitis Complicated by Cortical Venous and Cerebral Sino-Venous Thrombosis

Stroke is common in tuberculous meningitis. Stroke commonly affects the tubercular zone, comprising the anterior part of the thalamus, caudate and the internal capsule (anterior limb and genu). Stroke, in tuberculous meningitis is predominantly arterial ischemic stroke, and is due to infiltrative, proliferative or necrotizing arteritis. Rarely, aneurysm formation and mycotic aneurysms have also been described. The authors describe the clinical and autopsy findings of a 27-mo-old boy with tuberculous meningitis whose course was complicated by arterial and venous strokes, and nonresponse to adequate and appropriate antitubercular therapy.