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Aggrohia A, Bhatia V, Saroch A, Pannu AK. Predicting cerebral infarction in tuberculous meningitis and its prognostic significance. Biomark Med 2024; 18:407-417. [PMID: 39041843 DOI: 10.1080/17520363.2024.2347194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/18/2024] [Indexed: 07/24/2024] Open
Abstract
Aim: Tuberculous meningitis (TBM) often causes cerebral infarction, but its predictive factors are not well understood. Methods: Patients aged ≥13 years admitted with TBM were enrolled prospectively. Cerebral infarction was diagnosed using magnetic resonance imaging. Results: Of 186 patients, 80 (43%) had infarction. Most infarctions were multiple and located in the cortical areas, basal ganglia and subcortical regions. Independent predictors of infarction at admission included high blood pressure, short illness duration, low Glasgow coma scale and hydrocephalus. Neuroimaging inflammation signs, cerebrospinal fluid analysis abnormalities and pre-existing cardiovascular risks did not predict infarction. In-hospital mortality was higher in TBM with infarction, particularly in those with advanced TBM (stage 3). Conclusion: Baseline parameters of raised intracranial pressure predict cerebral infarction in TBM.
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Affiliation(s)
- Asha Aggrohia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Vikas Bhatia
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education & Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
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Liu Q, Cao M, Shao N, Qin Y, Liu L, Zhang Q, Yang X. Development and validation of a new model for the early diagnosis of tuberculous meningitis in adults based on simple clinical and laboratory parameters. BMC Infect Dis 2023; 23:901. [PMID: 38129813 PMCID: PMC10740218 DOI: 10.1186/s12879-023-08922-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND The differential diagnosis between tuberculous meningitis (TBM) and viral meningitis (VM) or bacterial meningitis (BM) remains challenging in clinical practice, particularly in resource-limited settings. This study aimed to establish a diagnostic model that can accurately and early distinguish TBM from both VM and BM in adults based on simple clinical and laboratory parameters. METHODS Patients diagnosed with TBM or non-TBM (VM or BM) between January 2012 and October 2021 were retrospectively enrolled from the General Hospital (derivation cohort) and Branch Hospital (validation cohort) of Ningxia Medical University. Demographic characteristics, clinical symptoms, concomitant diseases, and cerebrospinal fluid (CSF) parameters were collated. Univariable logistic analysis was performed in the derivation cohort to identify significant variables (P < 0.05). A multivariable logistic regression model was constructed using these variables. We verified the performance including discrimination, calibration, and applicability of the model in both derivation and validation cohorts. RESULTS A total of 222 patients (70 TBM and 152 non-TBM [75 BM and 77 VM]) and 100 patients (32 TBM and 68 non-TBM [31 BM and 37 VM]) were enrolled as derivation and validation cohorts, respectively. The multivariable logistic regression model showed that disturbance of consciousness for > 5 days, weight loss > 5% of the original weight within 6 months, CSF lymphocyte ratio > 50%, CSF glucose concentration < 2.2 mmol/L, and secondary cerebral infarction were independently correlated with the diagnosis of TBM (P < 0.05). The nomogram model showed excellent discrimination (area under the curve 0.959 vs. 0.962) and great calibration (P-value in the Hosmer-Lemeshow test 0.128 vs. 0.863) in both derivation and validation cohorts. Clinical decision curve analysis showed that the model had good applicability in clinical practice and may benefit the entire population. CONCLUSIONS This multivariable diagnostic model may help clinicians in the early discrimination of TBM from VM and BM in adults based on simple clinical and laboratory parameters.
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Affiliation(s)
- Qiang Liu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China
- Graduate College of Ningxia Medical University, Yinchuan, 750004, Ningxia Province, China
| | - Meiling Cao
- Department of Internal Medicine, The Inner Mongolia Autonomous Region, The People's Hospital of Wushen Banner, Erdos, 017000, China
| | - Na Shao
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China
| | - Yixin Qin
- Department of Neurology, The First People's Hospital of Yinchuan, Yinchuan, 750004, Ningxia Province, China
| | - Lu Liu
- Graduate College of Ningxia Medical University, Yinchuan, 750004, Ningxia Province, China
| | - Qing Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China.
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China.
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Tomidy J, Satriadinatha GBY, Liwang FK, Maharani K, Imran D, Estiasari R. Prognostic identifier of cerebrovascular complications in tuberculous meningitis: Meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107371. [PMID: 37738916 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 09/03/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Cerebrovascular complications could occur in 15-57 % of patients with tuberculous meningitis (TBM). It is crucial to rapidly identify TBM patients who are at risk for stroke. This study aimed to find predictors of stroke in patients with TBM. METHODS This systematic review and meta-analysis were done using literature searches through online databases up to April 30th, 2022. Three independent authors performed literature screening, data extraction, and critical appraisal of the studies. Eight studies involving 1535 samples were included. RESULTS We analyzed data regarding demographic, comorbidity, clinical presentation, radiologic, and laboratory parameters. Overall, clinical presentation that showed outcome difference was found in patients with findings of vomiting (OR = 2.71, 95 % CI: 1.30-5.63), cranial nerve deficit (OR = 4.10, 95 % CI: 1.83-9.21), focal deficit (OR = 5.56, 95 % CI: 2.24-13.79), and altered consciousness (OR = 1.90, 95 % CI: 1.24-2.92). Some comorbidities showed significant differences such as diabetes mellitus (OR = 2.58, 95 % CI: 1.51-4.41), hypertension (OR = 5.73, 95 % CI: 3.36-9.77), ischemic heart disease (OR = 2.18, 95 % CI: 1.02-4.63), and smoking (OR = 2.65, 95 % CI: 1.22-5.77). Two radiological changes shown to have significantly higher proportions are hydrocephalus (OR = 2.50, 95 % CI: 1.74-3.58) and meningeal enhancements (OR = 3.99, 95 % CI: 1.73-9.20). CONCLUSION Our analysis indicated that clinical presentations of vomiting, cranial nerve deficit, focal deficit, altered consciousness; comorbidity of diabetes mellitus, hypertension, smoking history, ischemic heart disease; and radiological findings of meningeal enhancement and hydrocephalus showed significant association with stroke incidence in tuberculous meningitis.
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Affiliation(s)
- Julianto Tomidy
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Gede Bagus Yoga Satriadinatha
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Filbert Kurnia Liwang
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Kartika Maharani
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Riwanti Estiasari
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia.
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Gu Z, Liu B, Yu X, Cheng T, Han T, Tong L, Cao Y. Association of blood neutrophil-lymphocyte ratio with short-term prognosis and severity of tuberculosis meningitis patients without HIV infection. BMC Infect Dis 2023; 23:449. [PMID: 37407938 DOI: 10.1186/s12879-023-08438-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 07/03/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Predicting the short-term prognosis and severity of tuberculosis meningitis (TBM) patients without HIV infection can be challenging, and there have been no prior studies examining the neutrophil lymphocyte ratio (NLR) as a potential predictor of short-term prognosis or its relationship to TBM severity. We hypothesized that NLR might serve as an independent indicator of short-term prognostic significance and that there might be a correlation between NLR and severity. The aim of this study was to investigate the role of NLR as a predictor of short-term prognosis and its relationship to severity of tuberculosis meningitis patients without HIV infection. METHODS We retrospectively collected data from patients diagnosed with TBM in the West China Hospital, Sichuan University, from the period between January 1st, 2018 and August 1st, 2019. Multivariable analysis was executed by the logistic regression model to verify the independence of the 28-day mortality, the discriminative power for predicting short-term prognosis was evaluated using a Receiver Operating Characteristic (ROC) curve, survival outcomes were analyzed using the Kaplan-Meier method and Pearson's correlation analysis was performed to discuss correlation between NLR and the severity of TBM. RESULTS We collected data from 231 TBM patients without HIV infection. 68 (29.4%) patients are classified as stage (I) 138(59.8%) patients are stage (II) 25(10.8%) patients are stage (III) 16(6.9%) patients died during the follow-up period of 28 days. By multiple logistic regression analyses, the NLR (OR = 1.065, 95% CI = 1.001-1.133, P = 0.045), peripheral neurological deficit (OR 7.335, 95% CI 1.964-27.385, P = 0 0.003) and hydrocephalus (OR 11.338, 95% CI 2.397-53.633, P = 0 0.002) are independent risk factors of 28-day mortality. The area under the ROC curve (AUC) for predicting short prognosis using NLR is 0.683 (95% CI 0.540-0.826, P = 0.015), the optimal cutoff value is 9.99(sensitivity: 56.3%, specificity: 80.9%). The Kaplan-Meier analysis demonstrated that patients with higher NLR(>9.99) had significantly worse survival outcomes(P<0.01).Pearson's correlation analysis presents a significant positive correlation between the severity of TBM and NLR (r = 0.234, P<0.01). CONCLUSIONS NLR, peripheral neurological deficit, and hydrocephalus are independent risk factors of 28-day mortality, NLR can predict the short-term prognosis of TBM patients without HIV infection. NLR is also found to be significantly and positively correlated with the severity of TBM.
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Affiliation(s)
- Zhihan Gu
- Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Bofu Liu
- Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiaomin Yu
- Disaster Medical Center, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Tao Cheng
- Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Tianyong Han
- Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Le Tong
- Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Yu Cao
- Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China.
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Concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated with miliary tuberculosis. Acta Neurochir (Wien) 2023; 165:647-650. [PMID: 36624232 DOI: 10.1007/s00701-023-05489-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023]
Abstract
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.
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Harahap MIR, Soetikno RD, Anwary F. Relationship between neutrophil count in cerebrospinal fluid and cerebral infarct appearance in head MRI on tuberculous meningitis patients. Eur J Radiol Open 2022; 10:100469. [PMID: 36578907 PMCID: PMC9791119 DOI: 10.1016/j.ejro.2022.100469] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/27/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives To determine the relationship between neutrophils count in cerebrospinal fluid and cerebral infarction in head magnetic resonance imaging (MRI) on patients with tuberculous meningitis. Methods A diagnostic study was done on patients with tuberculous meningitis (TBM) who underwent head MRI examination and cerebrospinal fluid analysis at Dr. Hasan Sadikin General Hospital from January 2015 to September 2016. TBM was diagnosed by Mycobacterium tuberculosis isolation from cerebrospinal fluid. Cut-off value of neutrophil count was determined using receiver operating characteristics (ROC) curve. Conformity test was done using Kappa test. Results Thirty seven subjects were recruited in this study. Higher neutrophil count in CSF was observed on subjects with cerebral infarction (p < 0.05). Cut-off value of neutrophil count in CSF was determined as > 41 %. There was a moderate conformity between higher neutrophil count in CSF and cerebral infarction appearance in MRI (p < 0.05, Kappa score 0.529). Conclusion Higher neutrophil count was associated with the appearance of cerebral infarct in head MRI on adult patients with tuberculous meningitis.
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Affiliation(s)
- Muhammad Irvanie Rama Harahap
- Correspondence to: Department of Radiology, Hasan Sadikin National General Hospital, Jl. Pasteur No.38, Kota, Bandung, Jawa Barat 40161, Indonesia.
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Sy MCC, Espiritu AI, Pascual JLR. Global Frequency and Clinical Features of Stroke in Patients With Tuberculous Meningitis: A Systematic Review. JAMA Netw Open 2022; 5:e2229282. [PMID: 36048445 PMCID: PMC9437750 DOI: 10.1001/jamanetworkopen.2022.29282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Marie Charmaine C. Sy
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Adrian I. Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Jose Leonard R. Pascual
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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Kumar A, Mudassir S, Sinha N, Babanrao WB, Ranjan A. Stroke in Tuberculous Meningitis and Its correlation with Magnetic Resonance Angiography Manifestations. J Neurosci Rural Pract 2022; 13:417-423. [PMID: 35946026 PMCID: PMC9357505 DOI: 10.1055/s-0042-1745713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective
The primary objective of the study was to assess the location of cerebral infarction and look for corresponding magnetic resonance angiography (MRA) changes in patients with tuberculous meningitis (TBM). We also evaluated the predictors of ischemic stroke in TBM and the impact of these infarctions on patient's outcome.
Methods
This was a single-center prospective study between September 2018 and September 2020. Demographic and laboratory parameters were noted. Cranial magnetic resonance imaging and MRA were performed at the time of admission to the hospital.
Results
Among 120 patients with TBM, 46 had stroke. Nineteen (15.8%) patients died, of which 12 (10%) suffered from stroke. The most common site of infarction was the basal ganglia (54.3%). The commonest site of MRA abnormalities was the middle cerebral artery (39.1%). British Medical Research Council (BMRC) stage 3, cerebrospinal fluid (CSF) sugar, CSF adenosine deaminase (ADA) level, basal exudates, hydrocephalus, and hyponatremia were found to be predictors of stroke in TBM, while BMRC stage 3, CSF cell count, CSF ADA level, and anemia were found to be significantly associated with mortality in TBM patients with stroke.
Conclusion
The basal ganglia were the most common site of ischemic stroke in TBM, and middle cerebral artery was the most often involved intracranial blood vessel. BMRC stage 3 was significantly associated with both stroke and mortality in TBM patients with stroke.
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Affiliation(s)
- Ashok Kumar
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Sanaullah Mudassir
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Neetu Sinha
- Department of Radiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | | | - Abhay Ranjan
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
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Cao X, Yang Q, Zhou X, Lv K, Zhou Z, Sun F, Ruan Q, Zhang J, Shao L, Geng D. Cerebral Infarction and Evan's Ratio on MRI Affect the Severity and Prognosis of Tuberculosis Meningitis Patients. Diagnostics (Basel) 2022; 12:1264. [PMID: 35626418 PMCID: PMC9141437 DOI: 10.3390/diagnostics12051264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/03/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) is widely used in the diagnosis of tuberculous meningitis (TBM) and its complications. We aimed to explore the relationship between MRI features and neurological deficits and TBM patients’ prognosis. Methods: patients diagnosed with TBM were subjected to a neurological evaluation on admission and divided into groups based on the Medical Research Council (MRC) scale. After several years of follow-up, the patients were further divided into groups according to the Modified Rankin Score (MRS). Their MR images were analyzed for meningeal enhancement, tuberculomas, infarction, hydrocephalus, and abscess, including the location and size of the lesion. Any changes in MRI features during the follow-up were recorded. MRI features between groups were compared, and the relationship between dynamic changes in images and Rankin grading was explored. Results: We found significant differences in acute cerebral infarction (ACI) and old cerebral infarctions (OCI) between the MRC groups, and the ORs of ACI and OCI were 21.818 (95% CI: 2.440−195.075) and 6.788 (95% CI: 1.516−30.392), respectively. There were significant differences in ACI, OCI, and Evan’s ratio between the MRS groups (p < 0.05), and the ORs of ACI, OCI, and hydrocephalus were 6.375 (95% CI: 1.501−27.080), 5.556 (95% CI: 1.332−23.177), and 9.139 (95% CI: 2.052−40.700), respectively. The changes of Evan’s ratio were related to the MRS grading (r = 0.335, p = 0.040). Conclusions: For patients with TBM, the presence of ACI or OCI is associated with neurological deficits, and ACI, OCI, and hydrocephalus can be regarded as poor prognostic predictors. Changes in Evan’s ratio will affect the outcome.
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Affiliation(s)
- Xin Cao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
| | - Qingluan Yang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xian Zhou
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Kun Lv
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
| | - Zhe Zhou
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
| | - Feng Sun
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qiaoling Ruan
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jun Zhang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
| | - Lingyun Shao
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Daoying Geng
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
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Predictors of Infarction in Tuberculous Meningitis in Indian Patients. J Stroke Cerebrovasc Dis 2021; 30:106088. [PMID: 34536810 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/02/2021] [Accepted: 08/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Stroke is a devastating complication of tuberculous meningitis (TBM) and is an important determinant of its outcome. We propose a model which would help to predict development of infarction or cerebrovascular events in patients of TBM. METHODS A prospective study with n=129 patients of TBM were evaluated for predictors and outcomes of stroke. A diagnostic grid was formulated with clinical, laboratory and radiology as parameters to predict the vascular outcomes. All patients were followed up for mortality and disability on the basis of modified rankin score (mRS). MRI & CSF cytokines TNF-alpha, IFN- gamma & IL-6,8, 10 were measured at baseline and 3 months. The diagnosis of TBM included definite, probable & possible types and stage I & II with early and late onset of symptoms respectively. RESULTS The mortality was 16.2% and 19.4% of all patients developed stroke. The mean GCS, barthel index and mRS at admission was 57.03± 9.5,10.2±2.3 & 3.3±0.03 respectively mild to moderate infection and functional limitation. Barthel index (BI) happened to be a strong predictor [F=32.6, p=0.001, t=15.5, βeta coefficient =0.002] followed by biomarker TNF-α [F=18.9, p=0.02, t= -2.07, βeta coefficient=-0.04]. N=25 patients developed stroke with TNF-α, IL-6, IFN -γ showing statistically significant increase in all the stroke affected TBM (95% CI; 4.5 to 1.2; p=0.003). At 3 months, it was observed that mRS was statistically significant between stage I & II (95% CI; 5.4 to 2.1; p=0.04). CONCLUSIONS Our data revealed that 19.4% patients developed vascular events during the hospital stay or follow up. We recruited late onset TBM as compared to early onset. BI, TNF-α, IL6 are most potent predictors of stroke post TBM.
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Abstract
Tuberculous (TB) meningitis (TBM), accounting for 70-80% of cases of neurotuberculosis, is one of the most severe forms of extrapulmonary tuberculosis. Two-thirds of new TB cases come from eight countries. Polymorphisms in toll-interleukin-1 receptor domain and in leukotriene A4 hydrolase (LTA4H) gene, affect the risk of inflammation in TBM. The common site of tuberculoma in children is cerebellum, and they may rarely develop tuberculous encephalopathy which has a high mortality. Young females with a high cerebrospinal fluid (CSF) protein have an increased predisposition to develop optochiasmatic arachnoiditis. Spinal TB meningitis may mimic transverse myelitis or Guillain-Barre syndrome. An extra-neural focus of TB should be sought clinically and radiologically as it may indicate safer and more accessible sites for diagnostic samplings. Cartridge-based nucleic acid amplification test (CBNAAT), also known as Genexpert test, is a polymerase chain reaction (PCR)-based method for detection of TB which also detects rifampicin resistance as it targets the rpob gene of mycobacteria. Line probe assays, based on PCR and reverse hybridization methods, identify mutations associated with drug resistance within a week. TBM being a paucibacillary disease, often evades a definite diagnosis and empirical treatment for a minimum of 9 months is warranted based on clinical judgement. All TBM patients should receive adjunctive corticosteroids, even those with HIV infection. Drug resistance is strongly associated with previous treatment and bedaquiline as well as delamanid have received approvals for multidrug resistant (MDR) TB. The key principle of managing MDR TB is never to add a single drug to a failing regimen. Correct combination and duration of most effective second line drugs in MDR TB require further modifications. Early shunting should be considered in those with hydrocephalus failing medical management. The single most important determinant of outcome is the stage of TBM at which treatment has been started.
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Stadelman AM, Ellis J, Samuels THA, Mutengesa E, Dobbin J, Ssebambulidde K, Rutakingirwa MK, Tugume L, Boulware DR, Grint D, Cresswell FV. Treatment Outcomes in Adult Tuberculous Meningitis: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2020; 7:ofaa257. [PMID: 32818138 PMCID: PMC7423296 DOI: 10.1093/ofid/ofaa257] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/23/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is substantial variation in the reported treatment outcomes for adult tuberculous meningitis (TBM). Data on survival and neurological disability by continent and HIV serostatus are scarce. METHODS We performed a systematic review and meta-analysis to characterize treatment outcomes for adult TBM. Following a systematic literature search (MEDLINE and EMBASE), studies underwent duplicate screening by independent reviewers in 2 stages to assess eligibility for inclusion. Two independent reviewers extracted data from included studies. We employed a random effects model for all meta-analyses. We evaluated heterogeneity by the I 2 statistic. RESULTS We assessed 2197 records for eligibility; 39 primary research articles met our inclusion criteria, reporting on treatment outcomes for 5752 adults with TBM. The commonest reported outcome measure was 6-month mortality. Pooled 6-month mortality was 24% and showed significant heterogeneity (I 2 > 95%; P < .01). Mortality ranged from 2% to 67% in Asian studies and from 23% to 80% in Sub-Saharan African studies. Mortality was significantly worse in HIV-positive adults at 57% (95% CI, 48%-67%), compared with 16% (95% CI, 10%-24%) in HIV-negative adults (P < .01). Physical disability was reported in 32% (95% CI, 22%-43%) of adult TBM survivors. There was considerable heterogeneity between studies in all meta-analyses, with I 2 statistics consistently >50%. CONCLUSIONS Mortality in adult TBM is high and varies considerably by continent and HIV status. The highest mortality is among HIV-positive adults in Sub-Saharan Africa. Standardized reporting of treatment outcomes will be essential to improve future data quality and increase potential for data sharing, meta-analyses, and facilitating multicenter tuberculosis research to improve outcomes.
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Affiliation(s)
- Anna M Stadelman
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jayne Ellis
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Ernest Mutengesa
- Hillingdon Hospital, The Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Joanna Dobbin
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel Grint
- Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
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Soni N, Kumar S, Shimle A, Ora M, Bathla G, Mishra P. Cerebrovascular complications in tuberculous meningitis-A magnetic resonance imaging study in 90 patients from a tertiary care hospital. Neuroradiol J 2020; 33:3-16. [PMID: 31589101 PMCID: PMC7005991 DOI: 10.1177/1971400919881188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Neetu Soni
- Neuroradiology Department,
University
of Iowa Hospitals and Clinics, USA
| | - Sunil Kumar
- Radiology Department, Sanjay Gandhi
Postgraduate Institute of Medical Sciences
(SGPGIMS),
India
| | - Anil Shimle
- Radiology Department, Sanjay Gandhi
Postgraduate Institute of Medical Sciences
(SGPGIMS),
India
| | - Manish Ora
- Nuclear Medicine Department,
SGPGIMS,
India
| | - Girish Bathla
- Radiology Department,
University
of Iowa Hospitals and Clinics, USA
| | - Prabhakar Mishra
- Department of Biostatistics and Health
Informatics,
SGPGIMS,
India
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Di Napoli A, Cristofaro M, Romano A, Pianura E, Papale G, Di Stefano F, Ronconi E, Petrone A, Rossi Espagnet MC, Schininà V, Bozzao A. Central Nervous System involvement in tuberculosis: An MRI study considering differences between patients with and without Human Immunodeficiency Virus 1 infection. J Neuroradiol 2019; 47:334-338. [PMID: 31539581 DOI: 10.1016/j.neurad.2019.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/21/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is largely used in the diagnosis of central nervous system involvement of tuberculosis (CNSTB), yet there is no MRI comparison study between HIV+ and HIV- patients with CNSTB. The aim of the present study was to identify MRI differences in CNSTB between HIV+ and HIV- patients and possibly find early characteristics that could raise the suspect of this disease. METHODS We included all patients admitted in our institution between 2011 and 2018 with confirmed diagnosis of CNSTB, and MRI performed in the first week. Patients with preexisting brain pathology or immunodeficiency not HIV related were excluded. We compared CNSTB MRI features between the two groups. RESULTS Sixty-nine patients were included (19 HIV+; 50 HIV-). Findings in HIV+ group: 6 lung TB, 5 hydrocephalus, 4 meningeal enhancement, 6 stroke, 2 hemorrhages, and 10 tuberculomas. HIV- group: 22 lung tuberculosis, 15 hydrocephalus, 21 meningeal enhancement, 5 stroke, 4 hemorrhages, 20 tuberculomas. The only statistically significant difference between the two groups was in the stroke occurrence, more frequent in the HIV+ group (P=.028), all involving the basal ganglia. CONCLUSIONS Stroke involving the basal ganglia best differentiates CNSTB patients who are HIV+ from those HIV-. This finding was not correlated with meningeal enhancement suggesting that small arteries involvement might precede it. Therefore, we think that HIV+ patients with a new onset of stroke should be evaluated for CNSTB. Follow-up MRI should also be planned since meningeal enhancement might appear in later stages of the disease.
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Affiliation(s)
- Alberto Di Napoli
- NESMOS Department University of Rome Sapienza. Azienda Ospedaliero-Universitaria Sant'Andrea, Roma, Italy
| | - Massimo Cristofaro
- Department of Diagnostic Imaging, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Roma, Italy
| | - Andrea Romano
- NESMOS Department University of Rome Sapienza. Azienda Ospedaliero-Universitaria Sant'Andrea, Roma, Italy
| | - Elisa Pianura
- Department of Diagnostic Imaging, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Roma, Italy
| | - Gioia Papale
- NESMOS Department University of Rome Sapienza. Azienda Ospedaliero-Universitaria Sant'Andrea, Roma, Italy
| | - Federica Di Stefano
- Department of Diagnostic Imaging, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Roma, Italy
| | - Edoardo Ronconi
- NESMOS Department University of Rome Sapienza. Azienda Ospedaliero-Universitaria Sant'Andrea, Roma, Italy
| | - Ada Petrone
- Department of Diagnostic Imaging, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Roma, Italy
| | | | - Vincenzo Schininà
- Department of Diagnostic Imaging, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Roma, Italy.
| | - Alessandro Bozzao
- NESMOS Department University of Rome Sapienza. Azienda Ospedaliero-Universitaria Sant'Andrea, Roma, Italy
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Zhang L, Zhang X, Li H, Chen G, Zhu M. Acute ischemic stroke in young adults with tuberculous meningitis. BMC Infect Dis 2019; 19:362. [PMID: 31039747 PMCID: PMC6492375 DOI: 10.1186/s12879-019-4004-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 04/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background Ischemic stroke is a common complication in patients with tuberculous meningitis (TBM), which is associated with poor clinical outcome. However, risk factors of stroke in TBM patients were not fully understood, especially in those young adults. Therefore, the aim of our study was to identify risk factors for acute ischemic stroke in young adults with TBM. Methods TBM patients (18 to 50 years) without cerebral vascular risk factors were prospective recruited between Feb 2014 and Dec 2017. Patients were defined as stroke group and non-stroke group by brain magnetic resonance imaging (MRI). Demographic characteristics, clinical presentations, cerebrospinal fluid (CSF) examination, basal meningeal enhancement, hydrocephalus, tuberculoma and clinical outcome were compared between two groups. Binary logistic regression was performed to determine risk factors for acute ischemic stroke in young TBM patients. Results Fifty-two patients with TBM were included and 12 (23.1%) patients were in stroke group. Patients in stroke group were older. Clinical presentations were comparable between two groups except headache was more common in TBM patients with stroke. In CSF examination, TBM patients with stroke had higher CSF white blood cell. By MRI, patients in stroke group were more likely to have basal meningeal enhancement but less likely to present tuberculoma. Compared to non-stroke group, patients in stroke group had worse short-term clinical outcome. In logistic regression, age (OR = 1.297; 95%CI 1.067, 1.576), CSF white blood cell (OR = 1.023; 95%CI 1.005, 1.042) and basal meningeal enhancement (OR = 23.913; 95%CI 1.398, 408.975) were independent risk factors for stroke. However, tuberculoma (OR = 0.005; 95%CI 0.000, 0.254) was negative related with stroke. Conclusions About a quarter of young adults with TBM have acute ischemic stroke which may lead to poor clinical outcome. Age, CSF white blood cell and basal meningeal enhancement are risk factors for acute ischemic stroke in young adults with TBM.
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Affiliation(s)
- Liming Zhang
- Department of Pulmonary and Critical Care Medicine, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, 404100, China
| | - Xiaoyu Zhang
- Department of Neurology, Qianfoshan Hospital, Shandong University, Jinan, 250014, China
| | - Huaqiang Li
- Department of Pulmonary and Critical Care Medicine, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, 404100, China.,Imaging department, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, 404100, China
| | - Gang Chen
- Department of Pulmonary and Critical Care Medicine, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, 404100, China.
| | - Meijia Zhu
- Department of Neurology, Qianfoshan Hospital, Shandong University, Jinan, 250014, China.
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Wasay M, Khan M, Farooq S, Khowaja ZA, Bawa ZA, Mansoor Ali S, Awan S, Beg MA. Frequency and Impact of Cerebral Infarctions in Patients With Tuberculous Meningitis. Stroke 2018; 49:2288-2293. [DOI: 10.1161/strokeaha.118.021301] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Cerebral infarctions complicate a variable proportion of tuberculous meningitis (TBM) cases and adversely affect outcomes. The objective of this study was to evaluate the predictors of cerebral infarcts in patients with TBM and to assess their impact on mortality.
Methods—
The study was based on a retrospective chart review of all patients with TBM admitted to a tertiary care hospital between 2002 and 2013. Data were collected on basic demographics, conventional vascular risk factors, radiological findings, severity of TBM, and neurological outcomes. Data were analyzed using SPSS version 19.0. Binary logistic regression was done to determine the factors predictive of cerebral infarcts and of mortality in patients with TBM.
Results—
A total of 559 patients were admitted with TBM during the study period. Mean age was 41.9 years (SD, 17.7 years), and 47% were women. A quarter of the patients had stage III disease. One hundred forty-four (25.8%) patients had cerebral infarcts on brain imaging of which 3 quarters were acute or subacute. Those with cerebral infarcts were more likely to be >40 years of age (adjusted odds ratio [AOR], 1.7; 95% CI, 1.1–2.7) and to have hypertension (AOR, 1.8; 95% CI, 1.1–2.8), dyslipidemia (AOR, 9.7; 95% CI, 3.8–24.8), and diabetes mellitus (AOR, 2.2; 95% CI, 1.3–3.6). Presence of cerebral infarction was an independent predictor of mortality among patients with TBM (AOR, 2.1; 95% CI, 1.22–3.5).
Conclusions—
Cerebral infarcts complicate a substantial proportion of TBM cases. Conventional vascular risk factors are the most important predictors of infarction, and future efforts need to focus on these high-risk patients with TBM to reduce morbidity and mortality.
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Affiliation(s)
- Mohammad Wasay
- From the Departments of Neurology (M.W., S.F.), Aga Khan University, Karachi, Pakistan
| | - Maria Khan
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates (M.K.)
| | - Salman Farooq
- From the Departments of Neurology (M.W., S.F.), Aga Khan University, Karachi, Pakistan
| | - Zubair Ali Khowaja
- Department of Physical Medicine and Rehabilitation, Institute of Physical Medicine and Rehabilitation, Dow University of Health Sciences, Karachi, Pakistan (Z.A.K.)
| | - Zeeshan Ali Bawa
- Department of Medicine, Ankleseria Hospital, Karachi, Pakistan (Z.A.B.)
| | - Shehzad Mansoor Ali
- Department of Public Health, University of Texas Health Science, Houston (S.M.A.)
| | - Safia Awan
- Medicine (S.A.), Aga Khan University, Karachi, Pakistan
| | - M. Asim Beg
- Pathology and Microbiology (M.A.B.), Aga Khan University, Karachi, Pakistan
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Li K, Tang H, Yang Y, Li Q, Zhou Y, Ren M, Long X, Shen W, Hu R, Wang X, Zeng K. Clinical features, long-term clinical outcomes, and prognostic factors of tuberculous meningitis in West China: a multivariate analysis of 154 adults. Expert Rev Anti Infect Ther 2017; 15:629-635. [PMID: 28343419 DOI: 10.1080/14787210.2017.1309974] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Tuberculosis is prevalent in China, which is the second greatest contributor to the global tuberculosis burden. Tuberculosis meningitis (TBM) is the most severe disease form but few reports describe long-term clinical outcomes and prognostic factors. Thus, we studied these features in Chinese TBM patients. METHODS A retrospective follow-up study was used to collect clinical features and outcomes of adult TB meningitis at the First Affiliated Hospital of Chongqing Medical University from June 2012 to August 2015. Univariate analysis and multivariate analysis were used to identify predictive factors associated with outcomes at discharge and follow-up. RESULTS TBM patients (N = 154) were a median age of 41 years (range: 16-82 years). Median time to follow-up was 26.4 months (range: 9.3-46.5 months) and 31% had poor outcomes at follow-up and limb weakness (p = 0.016), lower GCS scores (p < 0.001), cranial-nerve palsy (p = 0.024), and hydrocephalus (p = 0.009) were closely associated with these poor outcomes. Furthermore, a high neutrophil to lymphocytes ratio, high D-dimer, a low albumin to globulin ratio and slow background of EEG associated with poor outcomes as well. CONCLUSIONS Mortality and disability associated with TBM are high in China. Limb weakness, GCS scores, cranial-nerve palsy and hydrocephalus were independent predictors of poor outcomes, and AGR, NLR, D-dimer, and EEG abnormalities may be prognostic factors of TBM.
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Affiliation(s)
- Kunyi Li
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Hong Tang
- b Department of Critical Care Medicine , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Yi Yang
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Qin Li
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Yuchuan Zhou
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Min Ren
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Xianghua Long
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Wenjing Shen
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Rong Hu
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Xuefeng Wang
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Kebin Zeng
- a Department of Neurology, Chongqing Key Laboratory of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
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Merkler AE, Reynolds AS, Gialdini G, Morris NA, Murthy SB, Thakur K, Kamel H. Neurological complications after tuberculous meningitis in a multi-state cohort in the United States. J Neurol Sci 2017; 375:460-463. [PMID: 28320186 DOI: 10.1016/j.jns.2017.02.051] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/18/2017] [Accepted: 02/23/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE To assess the rate of neurological complications and mortality after tuberculous meningitis in the United States. METHODS The authors performed a retrospective cohort study of all patients 18years or older hospitalized for tuberculous meningitis in California between 2005 and 2010, New York between 2006 and 2012, and Florida between 2005 and 2012. Outcomes of interest were mortality and the following neurological complications: stroke, seizure, hydrocephalus requiring a ventriculoperitoneal shunt, vision impairment, and hearing impairment. Kaplan-Meier survival statistics were used to assess the cumulative rate of neurological complications and death. Cox proportional hazards regression was used to compare rates of complications in patients with and without human immunodeficiency virus (HIV) after adjustment for comorbidities. RESULTS 806 patients with tuberculous meningitis were identified, among whom the cumulative rate of any complication or death was 55.4% (95% CI, 51.5-59.3%). More than two-thirds of complications occurred during the initial hospitalization for tuberculous meningitis. Individual neurological complications were not uncommon: the cumulative rate of stroke was 16.8% (95% CI, 14.0-20.0%), the rate of seizure was 18.8% (95% CI, 15.4-22.8%), and the rate of ventriculoperitoneal shunting was 8.4% (95% CI, 6.4-10.9%). Vision impairment occurred in 21.6% (95% CI, 18.5-25.1%) of patients and hearing impairment occurred in 6.8% (95% CI, 4.9-9.4%). The mortality rate was 21.5% (95% CI, 18.4-24.9%). Patients with HIV infection were not at increased risk of complications compared to patients without HIV (hazard ratio, 1.2; 95% CI, 0.9-1.6). CONCLUSIONS Tuberculous meningitis is associated with significant risk of neurological complications and death in the United States.
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Affiliation(s)
- Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, United States; Department of Neurology, Weill Cornell Medicine, New York, NY, United States.
| | - Alexandra S Reynolds
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Gino Gialdini
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, United States; Department of Neurology, Weill Cornell Medicine, New York, NY, United States
| | - Nicholas A Morris
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, United States; Department of Neurology, Weill Cornell Medicine, New York, NY, United States; Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, United States; Department of Neurology, Weill Cornell Medicine, New York, NY, United States
| | - Kiran Thakur
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, United States; Department of Neurology, Weill Cornell Medicine, New York, NY, United States
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19
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Caring and Collaborating A case study on a complex patient under multiple teams. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2017. [DOI: 10.21307/ajon-2017-105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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20
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Wasay M, Farooq S, Khowaja ZA, Bawa ZA, Ali SM, Awan S, Beg MA, Mehndiratta MM. Cerebral infarction and tuberculoma in central nervous system tuberculosis: frequency and prognostic implications. J Neurol Neurosurg Psychiatry 2014; 85:1260-4. [PMID: 24623792 DOI: 10.1136/jnnp-2013-307178] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tuberculoma and cerebral infarctions are serious complications of central nervous system (CNS) tuberculosis. However, there are no studies comparing prognostic value of tuberculoma and infarcts alone and in patients diagnosed with CNS tuberculosis. OBJECTIVE The objective of this study was to identify frequency and prognostic value of tuberculoma and cerebral infarcts in a large sample of CNS tuberculosis patients. METHODS Retrospective chart review of patients diagnosed with CNS tuberculosis in a tertiary care hospital in Pakistan over 10-year period was carried out. RESULTS There were 404 patients included in this study (mean age of 43 years). There were 209 (52%) men and 195 (48%) women. Tuberculoma were present in 202 subjects (50%) while infarcts were present in 25% patients. 147 (36%) had tuberculous meningitis (TBM) without tuberculoma or infarction on CT or MRI, 158 (39%) had TBM with intracranial tuberculomas, 60 (15%) had TBM with cerebral infarction while 39 (10%) had TBM with both tuberculoma and infarction. At discharge, 249 patients (62%) were either normal (Modified Rankin Score (MRS)=0) or mild to moderately disabled (MRS=1-3) while 82 patients (20%) had severe disability (MRS=4-5). 73 (18%) patients died (MRS=6) during hospitalisation. Using logistic regression analysis, significant predictors of poor outcome included old age, high TBM grading, presence of infarction and presence of hydrocephalus. CONCLUSIONS Tuberculomas were present in 50% of patients, while infarcts were present in 25%. Old age, TBM grading, presence of infarction and hydrocephalus were all predictors of poor outcome.
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Affiliation(s)
- Mohammad Wasay
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | - Safia Awan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - M Asim Beg
- Pathology and Microbiology, Aga Khan University, Karachi, Pakistan
| | - Man Mohan Mehndiratta
- Department of Neurology, Janakpuri Superspeciality Hospital, Janakpuri New Delhi, New Delhi, India
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Chen CH, Chang YJ, Sy HN, Chen WL, Yen HC. Risk assessment of the outcome for cerebral infarction in tuberculous meningitis. Rev Neurol (Paris) 2014; 170:512-9. [PMID: 25194476 DOI: 10.1016/j.neurol.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/10/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cerebral infarction in tuberculous meningitis is a major risk factor for permanent disability. This study assessed the clinical presentation of tuberculous meningitis and risks factors for cerebral infarction. OBSERVATION Thirty-eight adult patients with tuberculous meningitis were studied between 2002 and 2006. Clinical, radiological, and laboratory data of patients with cerebral infarction were compared with those of patients without cerebral infarction. Patients with cerebral infarction were significantly older (65.1 vs 52.1years), had higher risk assessment scores (3.7 vs 2.2), and more often had basal meningeal enhancement on imaging (92.3% vs 60.0%), mild to moderate sequelae (69.2% vs 4%), an overall poor brain outcome (69.2% vs 8%), aspirin prescription (84% vs 8%), and neurosurgical intervention for hydrocephalus (54.0% vs 16.0%). Cerebral infarction patients were also more likely to have experienced doctor-related delays in antituberculosis (61.5% vs 36%) and corticosteroid (61.5% vs 32%) therapy. DISCUSSION AND CONCLUSION The Framingham risk score would be an option for tuberculous meningitis patients to access cerebral infarction risk. Contrast-enhanced brain imaging is helpful for exploring basal meningeal enhancement, in order to obtain an early diagnosis. Antituberculosis, corticosteroid, and aspirin therapies should be started immediately when tuberculous meningitis is suspected.
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Affiliation(s)
- C-H Chen
- Division of infectious disease, department of internal medicine, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China; Department of Nursing, College of Medicine & Nursing, Hung Kuang University, Taichung, Republic of China.
| | - Y-J Chang
- Laboratory of epidemiology and biostatistics, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - H-N Sy
- Department of neurology, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - W L Chen
- Department of medical imaging, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - H-C Yen
- Department of neurosurgery, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
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Abstract
Tuberculous meningitis is especially common in young children and people with untreated HIV infection, and it kills or disables roughly half of everyone affected. Childhood disease can be prevented by vaccination and by giving prophylactic isoniazid to children exposed to infectious adults, although improvements in worldwide tuberculosis control would lead to more effective prevention. Diagnosis is difficult because clinical features are non-specific and laboratory tests are insensitive, and treatment delay is the strongest risk factor for death. Large doses of rifampicin and fluoroquinolones might improve outcome, and the beneficial effect of adjunctive corticosteroids on survival might be augmented by aspirin and could be predicted by screening for a polymorphism in LTA4H, which encodes an enzyme involved in eicosanoid synthesis. However, these advances are insufficient in the face of drug-resistant tuberculosis and HIV co-infection. Many questions remain about the best approaches to prevent, diagnose, and treat tuberculous meningitis, and there are still too few answers.
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