1
|
Das S, Ray BK, Nandi M, Mondal G, Paul DK. The Spectrum of Intracranial Arteriopathies and Ischemic Strokes in Pediatric Tubercular Meningitis: A Tricentric Study From Eastern India. Pediatr Neurol 2024; 157:57-69. [PMID: 38878674 DOI: 10.1016/j.pediatrneurol.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/11/2024] [Accepted: 04/28/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Addressing the need to uniformly classify arteriopathies among patients with arterial ischemic stroke (AIS) due to tubercular meningitis (TBM), we used the Childhood AIS Standardised Classification and Diagnostic Evaluation (CASCADE) criteria. METHODS This tri-centric prospective study included children aged 0.5-12 years with TBM and AIS. Magnetic resonance angiographies (MRAs) were done during admission and repeated 3 and 12 months after discharge. Arteriopathies were classified according to the primary CASCADE criteria. We used the modified Pediatric Alberta Stroke Programme Early Computed Tomography Score as an ordinal measure of infarct volume. The severity of arteriopathies was graded using the focal cerebral arteriopathy severity score (FCASS). The final outcomes were measured at the 12-month follow-up visit using the Pediatric Stroke Outcome Measure (PSOM). RESULTS Out of 55 patients, 64% had MRA-evidenced arteriopathies and 84% had multiple infarcts. The middle cerebral (46%) and internal carotid arteries (22%) were most commonly affected. The basal ganglia (70%) and the cerebral cortex (61%) were most commonly infarcted. CASCADE categories included 3b (40%), 1d (38%), 2b (16%), 2c (5%), progressive (32%), and stable (44%) arteriopathies. Younger age, hypertrophic pachymeningitis, cortical infarcts, recurrent strokes, progressive arteriopathies, EEG abnormalities, and mortality were significantly higher among patients with MRA-proven arteriopathies. Patients with progressive arteriopathies had a significantly higher prevalence of hypertrophic pachymeningitis, cortical infarcts, and recurrent strokes. FCASS correlated positively with outcomes measured by the Pediatric Stroke Outcome Measure and modified Pediatric Alberta Stroke Programme Early Computed Tomography Score. CONCLUSION The CASCADE classification clarified the arteriopathy patterns, enabling us to correlate them with the characteristics of the infarcts. FCASS is useful to grade the arteriopathy severity and progression in TBM.
Collapse
Affiliation(s)
- Suman Das
- Department of Neurology, North Bengal Medical College, Siliguri, West Bengal, India.
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Madhumita Nandi
- Department of Pediatric Medicine, North Bengal Medical College, Siliguri, West Bengal, India
| | - Gobinda Mondal
- Department of Pediatric Medicine, Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Dilip Kumar Paul
- Department of Pediatric Medicine, Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Kumar VS, Kumar VS. Localization of cerebral vasculopathy following bacterial meningitis: What can we learn about postinfective ischemic sequelae? Brain Circ 2023; 9:205-213. [PMID: 38284114 PMCID: PMC10821684 DOI: 10.4103/bc.bc_97_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 01/30/2024] Open
Abstract
Cerebrovascular complications of bacterial meningitis account for a high incidence of mortality and postinfective neurologic sequelae. Cerebrovascular complications occurring during acute bacterial meningitis are evident from angiographic evidence demonstrating arterial occlusion and vessel wall narrowing, histopathological studies demonstrating vessel wall changes, and radiographic studies demonstrating the presence of brain infarcts. Cerebrovascular disease during bacterial meningitis has been demonstrated in of Haemophilus influenzae, Streptococcus pneumonia, Group B Streptococcus, and Mycobacterium tuberculosis models of meningitis. Despite models of bacterial meningitis showing variable patterns of cerebral vasculopathy as a contributor to different aspects of postinfectious neurological decline, very few studies describe the predominant localization of cerebral vasculopathy with different meningitis causing pathogens. Thus, this review attempts to analyze the different locations of cerebral vasculopathic changes occuring in response to different microbial pathogens and provide a pathophysiologic basis for such an observation.
Collapse
Affiliation(s)
- Vivig Shantha Kumar
- Department of Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, California, United States of America
| | - Vignarth Shantha Kumar
- Department of Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, California, United States of America
| |
Collapse
|
4
|
Mengstu A, Belay S, Chakko MN, Bala A. Basal Ganglia Ischemic Stroke: The Unforeseen Progression of Tuberculosis Epididymo-Orchitis. Cureus 2023; 15:e46640. [PMID: 37937015 PMCID: PMC10627335 DOI: 10.7759/cureus.46640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/09/2023] Open
Abstract
Tuberculosis is an infectious disease with broad pulmonary and extrapulmonary clinical manifestations. Central nervous system tuberculosis (CNS-TB) is a complex extrapulmonary infection known for its diverse clinical features including meningitis, tuberculoma, and spinal arachnoiditis. Particularly, tuberculosis meningitis can further lead to complications such as ischemic stroke. This article presents a challenging case of a 35-year-old male patient initially diagnosed with epididymo-orchitis, followed by viral-like central nervous system symptoms, ultimately complicated by tuberculosis meningitis and basal ganglia ischemic stroke. This case presentation underscores the diagnostic complexities associated with CNS-TB and emphasizes on the critical need for heightened awareness of the wide-ranging clinical presentations that can potentially delay early disease recognition and management.
Collapse
Affiliation(s)
- Abraham Mengstu
- Radiology, Ascension Providence Hospital/Michigan State University College of Human Medicine, Southfield, USA
| | - Seti Belay
- Radiology, Ascension Providence Hospital/Michigan State University College of Human Medicine, Southfield, USA
| | - Mathew N Chakko
- Radiology, Ascension Providence Hospital/Michigan State University College of Human Medicine, Southfield, USA
| | - Adithya Bala
- Radiology, Rochester Regional Health/Rochester General Hospital, Rochester, USA
| |
Collapse
|
5
|
Wen A, Cao WF, Liu SM, Zhou YL, Xiang ZB, Hu F, Wu LF, Cai W, Leng EL. Incidence and Risk Factors of Cranial Nerve Palsy in Patients with Tuberculous Meningitis: A Retrospective Evaluation. Infect Drug Resist 2023; 16:829-841. [PMID: 36820083 PMCID: PMC9938703 DOI: 10.2147/idr.s396022] [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: 11/03/2022] [Accepted: 01/03/2023] [Indexed: 02/16/2023] Open
Abstract
Objective Tuberculous meningitis (TBM) is a common form of central nervous system (CNS) tuberculosis (TB). Cranial nerve palsy is a serious complication of TBM. Literature regarding this subject is still limited in China. This study evaluated the incidence of cranial nerve palsy in patients with TBM in South China, its association with the clinical forms of TB, and other patient characteristics. Methods A retrospective chart review of patients with a diagnosis of TBM between January 2004 and December 2019 was conducted, and the demographic characteristics, clinical characteristics, and laboratory results of 114 patients were collected and followed up for 3 months. A multivariate logistic regression analysis model was used to explore the risk factors of cranial nerve palsy in patients with TBM. Results A total of 114 patients were enrolled in this study. Cranial nerve palsy was observed in approximately 38 (33.3%) of TBM patients. Among them, 13 (28.3%) had optic nerve palsy, 24 (52.2%) had oculomotor nerve palsy, 5 (10.9%) had abducens nerve palsy, 2 (4.3%) had auditory nerve palsy, 1 (2.2%) had glossopharyngeal nerve palsy, and 1 (2.2%) had vagus nerve palsy. Using logistic regression analysis, focal neurological deficit, extracranial TB and cerebrospinal fluid (CSF) total white cell count (WCC) were shown to be risk factors for cranial nerve palsy. Conclusion The prevalence rate of cranial nerve palsy was 33.3% in patients with TBM. Focal neurological deficits, extracranial TB and CSF total WCC are important predictors of cranial nerve palsy in patients with TBM.
Collapse
Affiliation(s)
- An Wen
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Wen-Feng Cao
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Shi-Min Liu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Yong-Liang Zhou
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Zheng-Bing Xiang
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Fan Hu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Ling-Feng Wu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Wen Cai
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
- Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Er-Ling Leng
- Department of Pediatrics, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| |
Collapse
|
6
|
Duong MT, Rudie JD, Mohan S. Neuroimaging Patterns of Intracranial Infections: Meningitis, Cerebritis, and Their Complications. Neuroimaging Clin N Am 2023; 33:11-41. [PMID: 36404039 PMCID: PMC10904173 DOI: 10.1016/j.nic.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neuroimaging provides rapid, noninvasive visualization of central nervous system infections for optimal diagnosis and management. Generalizable and characteristic imaging patterns help radiologists distinguish different types of intracranial infections including meningitis and cerebritis from a variety of bacterial, viral, fungal, and/or parasitic causes. Here, we describe key radiologic patterns of meningeal enhancement and diffusion restriction through profiles of meningitis, cerebritis, abscess, and ventriculitis. We discuss various imaging modalities and recent diagnostic advances such as deep learning through a survey of intracranial pathogens and their radiographic findings. Moreover, we explore critical complications and differential diagnoses of intracranial infections.
Collapse
Affiliation(s)
- Michael Tran Duong
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jeffrey D Rudie
- Department of Radiology, Scripps Clinic and University of California San Diego, 10666 Torrey Pines Road, La Jolla, CA 92037, USA
| | - Suyash Mohan
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| |
Collapse
|
7
|
Tang S, Liu L, Xie Z, He Y, Zhang Y, Xie Y, Chen S, Liu Y, Wei Y, Liang Z. Acute Ischemic Stroke in Tubercular Meningitis Patients Without Conventional Vascular Risk Factors: A Retrospective Case Control Study. J Inflamm Res 2022; 15:6617-6627. [PMID: 36514357 PMCID: PMC9741832 DOI: 10.2147/jir.s392040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Ischemic stroke is a common complication in patients with tubercular meningitis (TBM). However, the risk factors for Ischemic stroke in TBM patients are not fully understood, especially in those patients without conventional vascular risk factors. The aim of the present study was to explore the clinical features and independent risk factors for tubercular meningitis-related Ischemic stroke (TBMRIS). Methods Tubercular meningitis patients with acute Ischemic stroke without conventional vascular risk factors were recruited between July 2010 and July 2020 as the TBMRIS group. Patients who solely had tubercular meningitis were recruited as the control group (TMB group). Demographic characteristics, clinical presentations, and cerebrospinal fluid (CSF) examinations were collected, and multiple logistic regression analysis was applied to analyse the independent risk factors for TBMRIS. Results A total of 70 TBMRIS patients and 70 TMB patients were enrolled. Most (82.86%) of the TBMRIS patients experienced Ischemic stroke events within 3 months after the diagnosis of tubercular meningitis. The multiple logistic regression analysis revealed that variation in red blood cell distribution width (RDW-CV), mean platelet volume (MVP), C-reactive protein (CRP), CSF glucose and Modified Research Council Grade II (MRC Grade II) were independent risk factors for TBRIS. The AUC of the identification model was 0.808, with a sensitivity of 68.60% and a specificity of 84.30%. Conclusion This study revealed that RDW-CV, MVP, CRP, CSF glucose and MRC Grade II are potential independent risk factors for TBMRIS. The identification model established in this study may help monitor TBM patients who are at high risk of developing TBMRIS.
Collapse
Affiliation(s)
- Shiting Tang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, People’s Republic of China
| | - Liuyu Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, People’s Republic of China
| | - Zhouhua Xie
- Department of Tuberculosis, The Fourth People’s Hospital of Nanning City, Nanning, People’s Republic of China
| | - Yaoqin He
- Department of Tuberculosis, The Fourth People’s Hospital of Nanning City, Nanning, People’s Republic of China
| | - Yunli Zhang
- Department of Neurology, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
| | - Yiju Xie
- Department of Neurology, Wuming Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Shijian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, People’s Republic of China
| | - Yayuan Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, People’s Republic of China
| | - Yunfei Wei
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, People’s Republic of China,Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China,Yunfei Wei, Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China, Email
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, People’s Republic of China,Correspondence: Zhijian Liang, Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Key Laboratory of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, People’s Republic of China, Email
| |
Collapse
|
8
|
Liu C, Huai R, Xiang Y, Han X, Chen Z, Liu Y, Liu X, Liu H, Zhang H, Wang S, Hao L, Bo Y, Luo Y, Wang Y, Wang Y. High cerebrospinal fluid lactate concentration at 48 h of hospital admission predicts poor outcomes in patients with tuberculous meningitis: A multicenter retrospective cohort study. Front Neurol 2022; 13:989832. [PMID: 36277931 PMCID: PMC9583930 DOI: 10.3389/fneur.2022.989832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Objective This study aimed to analyze the cerebrospinal fluid (CSF) parameters affecting the outcomes of patients with tuberculous meningitis (TBM). Methods This is a multi-center, retrospective, cohort study involving 81 patients who were diagnosed with TBM and treated in Haihe Clinical College of Tianjin Medical University, Tianjin Medical University General Hospital, and General Hospital of Air Force PLA from January 2016 to December 2019. Baseline data, Glasgow Coma Scale (GCS) score, and clinical presentations of all patients were collected at admission. CSF samples were collected at 48 h, 1, 2, and 3 weeks after admission. CSF lactate, adenosine deaminase, chloride, protein, glucose levels and intracranial pressure were measured. After a follow-up of 16.14 ± 3.03 months, all patients were assessed using the modified Rankin Scale (mRS) and divided into good (mRS scores of 0–2 points) and poor outcome groups (mRS scores of 3–6 points). The differences in patients' baseline data, GCS score, clinical presentations, and levels of CSF parameters detected at 48 h, 1, 2, and 3 weeks after admission between two groups were compared. Statistically significant variables were added to the binary logistic regression model to identify the factors impacting the outcomes of patients with TBM. Receiver operating characteristic (ROC) curve was used to assess the predictive ability of the model. Results The CSF lactate level exhibited a decreasing trend within 3 weeks of admission in the two groups. For the within-group comparison, statistically significant differences in the lactate level was found in both groups between four different time points. A binary logistic regression model revealed that CSF lactate level at 48 h after admission, age, and GSC score on admission were independently associated with the outcomes of patients with TBM. ROC curve analysis showed that the area under the ROC curve (AUC) was 0.786 for the CSF lactate level (48 h), 0.814 for GCS score, and 0.764 for age. Conclusion High CSF lactate level at 48 h after admission is one of the important factors for poor outcomes in patients with TBM.
Collapse
Affiliation(s)
- Chenchao Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Ruixue Huai
- Department of Neurology, Tianjin Jinnan Hospital, Tianjin, China
| | - Yijia Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Xu Han
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Zixiang Chen
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Yuhan Liu
- Department of Neurosurgery, People's Liberation Army Air Force Medical Center, Beijing, China
| | - Xingjun Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Huiquan Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Hong Zhang
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Rehabilitation Department, Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Sihan Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Lingyu Hao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yin Bo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yuanbo Luo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yiyi Wang
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Yiyi Wang
| | - Yi Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
- *Correspondence: Yi Wang
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Yiek SH, Wong ASH. Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience. Asian J Neurosurg 2022; 17:189-198. [PMID: 36120621 PMCID: PMC9473842 DOI: 10.1055/s-0042-1750781] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Abstract
Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient.
Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined.
Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature.
Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.
Collapse
Affiliation(s)
- Siew-Hong Yiek
- Department of Neurosurgery, Sarawak General Hospital, Malaysia
| | | |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Gutierrez J, Katan M, Elkind MS. Inflammatory and Infectious Vasculopathies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00036-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
14
|
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.
Collapse
|
15
|
Agarwal A, Bathla G, Kanekar S. Imaging of Non-atherosclerotic Vasculopathies. J Clin Imaging Sci 2020; 10:62. [PMID: 33194304 PMCID: PMC7656038 DOI: 10.25259/jcis_91_2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/12/2020] [Indexed: 11/09/2022] Open
Abstract
Non-atherosclerotic vasculopathies (NAVs) may present with various neurological symptoms ranging from headache, stroke, visual symptoms, and various types of intracranial hemorrhage. NAVs result from different etiologies which include collagenopathies, immunological, hematological, and infection mechanisms, and other rarer unidentifiable or idiopathic causes. NAV etiologies account for about 10–15% and 20–25% of adult and pediatric stroke cases, respectively, and therefore, diagnosing the underlying cause of NAV becomes clinically very important. Clinical diagnosis of NAV is challenging because the clinical presentation is very non-specific and overlapping with various other central nervous system disorders. Before the advent of non-invasive techniques, making a diagnosis of non-atherosclerotic vasculopathy as a cause of the stroke was very challenging. Today with newer techniques such as high-resolution magnetic resonance (MR), MR and computed tomography perfusion, and angiogram, there are number of pointers which can give us a lead about the non-atherosclerotic causes. Imaging may provide the first lead to the clinician regarding the diagnosis or possible differential diagnosis so that the targeted and focused biomarkers (blood, cerebrospinal fluid, or/and in some cases biopsies) may be obtained to clinch the diagnoses. The purpose of the article is to enumerate the causes, clinical features, and illustrate the imaging findings of the various non-atherosclerotic vasculopathic disorders and discuss “pearls” to their diagnosis. In this article, we have also discussed the latest advances in vascular imaging and elaborated on few uncommon non-atherosclerotic vasculopathies. These are very relevant clinically in the day-to-day practice for the radiologist, neurologist, and the neurointerventionalist.
Collapse
Affiliation(s)
- Amit Agarwal
- Department of Radiology, University Texas Southwestern, Dallas, Texas
| | - Girish Bathla
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Sangam Kanekar
- Department of Radiology, Penn State Health, Hershey, Pennsylvania, United States
| |
Collapse
|
16
|
Tala-Ighil T, Greffe S, Trad S, Delaroche M, Coutte L, Rouveix E, Kahn JE, Hanslik T. [Cerebral infarction and tuberculosis: case report and literature review]. Rev Med Interne 2020; 41:704-707. [PMID: 32861533 DOI: 10.1016/j.revmed.2020.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/21/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Although tuberculous meningitis is an uncommon presentation of tuberculosis, it still remains one of the deadliest forms of this disease. In this context, the occurrence of a cerebral infarct is an aggravating factor. OBSERVATION A 48-year-old Asian man presented himself in the emergency room for dysarthria and dysphagia of progressive onset. Cerebral CT showed a recent ischemic defect of the right internal capsule. Lumbar puncture showed meningitis with low sugar levels. Pulmonary micronodules on the thoracic CT suggested tuberculosis, which was confirmed by a broncho-alveolar lavage. Anti-tuberculosis treatment and early corticosteroid resulted in an improvement of the patient's state. CONCLUSION Cerebral infarctions in patients with tuberculous meningitis are events that cannot be underestimated in terms of frequency or severity. Their poor prognosis is partly the result of insufficiently defined management, which combines anti-tuberculosis treatment and early corticosteroid therapy.
Collapse
Affiliation(s)
- T Tala-Ighil
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France.
| | - S Greffe
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - S Trad
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - M Delaroche
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - L Coutte
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - E Rouveix
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - J-E Kahn
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - T Hanslik
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| |
Collapse
|
17
|
Rohlwink UK, Chow FC, Wasserman S, Dian S, Lai RPJ, Chaidir L, Hamers RL, Wilkinson RJ, Boulware DR, Cresswell FV, van Laarhoven A. Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies. Wellcome Open Res 2020; 4:204. [PMID: 32399496 PMCID: PMC7194504 DOI: 10.12688/wellcomeopenres.15497.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 01/12/2023] Open
Abstract
Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints. Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.
Collapse
Affiliation(s)
- Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, Neuroscience Institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Felicia C Chow
- Weill Institute for Neurosciences and Departments of Neurology and Medicine (Infectious Diseases), University of California, San Francisco, USA
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Sofiati Dian
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rachel PJ Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Lidya Chaidir
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia,Faculty of Medicine, University of Indonesia, Jakarta, Indonesia,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa,The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK,Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda,MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands,
| | | |
Collapse
|
18
|
Rohlwink UK, Chow FC, Wasserman S, Dian S, Lai RPJ, Chaidir L, Hamers RL, Wilkinson RJ, Boulware DR, Cresswell FV, van Laarhoven A. Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies. Wellcome Open Res 2020; 4:204. [PMID: 32399496 PMCID: PMC7194504 DOI: 10.12688/wellcomeopenres.15497.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2019] [Indexed: 12/26/2022] Open
Abstract
Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints. Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.
Collapse
Affiliation(s)
- Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, Neuroscience Institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Felicia C Chow
- Weill Institute for Neurosciences and Departments of Neurology and Medicine (Infectious Diseases), University of California, San Francisco, USA
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Sofiati Dian
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rachel PJ Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Lidya Chaidir
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia,Faculty of Medicine, University of Indonesia, Jakarta, Indonesia,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa,The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK,Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda,MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands,
| | | |
Collapse
|
19
|
Rizvi I, Garg RK, Malhotra HS, Kumar N, Uniyal R. Role of Aspirin in Tuberculous Meningitis: A Systematic Review and Meta-analysis. Neurol India 2020; 67:993-1002. [PMID: 31512620 DOI: 10.4103/0028-3886.266232] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives Aspirin is a drug that has been found to be useful in reducing the incidence of infarctions. This systemic is aimed at review evaluating the benefits of aspirin in the management of tuberculous meningitis. Methods A systematic literature search was performed using PubMed, Cochrane Central Register of Controlled Trials, and SCOPUS for articles published on or before September 22, 2018. The meta-register of controlled trials and bibliography was also searched. Randomized controlled trials wherein aspirin was used were included in the systematic review. The data was extracted using a predetermined format. The risk ratio (RR) for dichotomous data was calculated and a random-effects model was used to combine the data. Death and occurrence of new infarctions were considered as primary outcomes. The quality of evidence was assessed using the GRADE approach. Results Four trials including 546 patients were found eligible. The addition of aspirin to anti-tuberculosis drug regimens did not significantly reduce mortality [RR = 0.66 (0.42-1.02); low-quality evidence] but significantly reduced the risk of new infarctions [RR = 0.52 (0.29-0.92); moderate-quality evidence]. Aspirin did not differ from the placebo with regard to the adverse event outcome. Conclusion Aspirin reduces the risk of new infarctions in patients with tuberculous meningitis but does not affect mortality (moderate-to-low level of evidence).
Collapse
Affiliation(s)
- Imran Rizvi
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Ravindra K Garg
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Hardeep S Malhotra
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Neeraj Kumar
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Ravi Uniyal
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Long B, Liang SY, Koyfman A, Gottlieb M. Tuberculosis: a focused review for the emergency medicine clinician. Am J Emerg Med 2019; 38:1014-1022. [PMID: 31902701 DOI: 10.1016/j.ajem.2019.12.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Tuberculosis (TB) is a common disease worldwide, affecting nearly one-third of the world's population. While TB has decreased in frequency in the United States, it remains an important infection to diagnose and treat. OBJECTIVE This narrative review discusses the evaluation and management of tuberculosis, with an emphasis on those factors most relevant for the emergency clinician. DISCUSSION TB is caused by Mycobacterium tuberculosis and is highly communicable through aerosolized particles. A minority of patients will develop symptomatic, primary disease. Most patients will overcome the initial infection or develop a latent infection, which can reactivate. Immunocompromised states increase the risk of primary and reactivation TB. Symptoms include fever, prolonged cough, weight loss, and hemoptysis. Initial diagnosis often includes a chest X-ray, followed by serial sputum cultures. If the patient has a normal immune system and a normal X-ray, active TB can be excluded. Newer tests, including nucleic acid amplification testing, can rapidly diagnose active TB with high sensitivity. Treatment for primary and reactivation TB differs from latent TB. Extrapulmonary forms can occur in a significant proportion of patients and involve a range of different organ systems. Patients with human immunodeficiency virus are high-risk and require specific considerations. CONCLUSIONS TB is a disease associated with significant morbidity and mortality. The emergency clinician must consider TB in the appropriate setting, based on history and examination. Accurate diagnosis and rapid therapy can improve patient outcomes and reduce the spread of this communicable disease.
Collapse
Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, United States; Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States
| |
Collapse
|
22
|
Abstract
PURPOSE OF REVIEW Describe the range of infectious causes of ocular motor neuropathies, from common presentations to unusual manifestations of diseases less frequently seen in the developed world. Provide information on recent developments in diagnostic testing for pathogens that may cause ocular motor neuropathies. RECENT FINDINGS Antigen detection in serum or CSF has improved the diagnosis of cryptococcal disease. Cartridge PCR testing for tuberculosis has increased diagnostic accuracy, though tuberculous meningitis remains difficult to diagnose. Rapid, multiplex PCR and unbiased sequencing allow for diagnosis of a wider range of organisms. SUMMARY Infectious ocular motor neuropathies can occur anywhere along the length of cranial nerves III, IV, and VI. Characteristic clinical findings and imaging can be used to localize infections. Infectious causes may have characteristic clinical, laboratory, or imaging findings, but must still be carefully separated from inflammatory or neoplastic conditions.
Collapse
|
23
|
Andriescu EC, Khetan NG, Mazur L, Smith KC. Tuberculosis Meningitis in a 10-Month-Old Living in an Immigrant Township. Clin Pediatr (Phila) 2019; 58:1341-1344. [PMID: 31167566 DOI: 10.1177/0009922819852997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
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.
Collapse
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.
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Abstract
Central nervous system (CNS) disease caused by Mycobacterium tuberculosis (MTB) is highly devastating. Tuberculous meningitis (TBM) is the most common form of CNS tuberculosis (TB). Rapid, sensitive, and affordable diagnostic tests are not available. Ziehl-Neelsen (ZN) stain has a very low sensitivity in cases of TBM, the sensitivity rates is of about 10-20%.The detection rate can be improved by taking large volume CSF samples (>6 ml) and prolonged slide examination (30 min). Culture of MTB from the CSF is slow and insufficiently sensitive. The sensitivity is different, which varies from 36% to 81.8%. The microscopic observation drug susceptibility (MODS) assay was recommended by the World Health Organization in 2011. The sensitivity is 65%, which is more sensitive and faster than CSF smear. Commercial PCR assays were found to be insensitive at detecting MTB in CSF samples. Many research provided the value of ADA on the TBM diagnosis. Interferon-gamma release assays (IGRAs) are not recommended for diagnosis of active TB disease. Imaging is essential in diagnosis and showing complications of CNS TB. Thwaites criteria and the Lancet consensus scoring system (LCSS) were developed to improve the diagnosis of TBM. Clinicians will continue to make judgment based on clinical examination, inflammatory CSF examinations, imaging studies, and scoring systems.
Collapse
Affiliation(s)
- Yi-Yi Wang
- Department of Neurology, Tianjin Haihe Hospital, Tianjin, P.R. China.
| | - Bing-di Xie
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, P.R. China
| |
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW Tuberculous meningitis is the most devastating manifestation of infection with Mycobacterium tuberculosis and represents a medical emergency. Approximately one half of tuberculous meningitis patients die or suffer severe neurologic disability. The goal of this review will be to review the pathogenic, clinical, and radiologic features of tuberculous meningitis and to highlight recent advancements in translational and clinical science. RECENT FINDINGS Pharmacologic therapy includes combination anti-tuberculosis drug regimens and adjunctive corticosteroids. It is becoming clear that a successful treatment outcome depends on an immune response that is neither too weak nor overly robust, and genetic determinants of this immune response may identify which patients will benefit from adjunctive corticosteroids. Recent clinical trials of intensified anti-tuberculosis treatment regimens conducted in Indonesia and Vietnam, motivated by the pharmacologic challenges of treating M. tuberculosis infections of the central nervous system, have yielded conflicting results regarding the survival benefit of intensified treatment regimens. More consistent findings have been observed regarding the relationship between initial anti-tuberculosis drug resistance and mortality among tuberculous meningitis patients. Prompt initiation of anti-tuberculosis treatment for all suspected cases remains a key aspect of management. Priorities for research include the improvement of diagnostic testing strategies and the optimization of host-directed and anti-tuberculosis therapies.
Collapse
|
29
|
Abstract
Central nervous system tuberculosis (CNS-TB) takes three clinical forms: meningitis (TBM), intracranial tuberculoma, and spinal arachnoiditis. TBM predominates in the western world and presents as a subacute to chronic meningitis syndrome with a prodrome of malaise, fever, and headache progressing to altered mentation and focal neurologic signs, followed by stupor, coma, and death within five to eight weeks of onset. The CSF formula typically shows a lymphocytic pleocytosis, and low glucose and high protein concentrations. Diagnosis rests on serial samples of CSF for smear and culture, combined with CSF PCR. Brain CT and MRI aid in diagnosis, assessment for complications, and monitoring of the clinical course. In a patient with compatible clinical features, the combination of meningeal enhancement and any degree of hydrocephalus is strongly suggestive of TBM. Vasculitis leading to infarcts in the basal ganglia occurs commonly and is a major determinant of morbidity and mortality. Treatment is most effective when started in the early stages of disease, and should be initiated promptly on the basis of strong clinical suspicion without waiting for laboratory confirmation. The initial 4 drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) covers the possibility of infection with a resistant strain, maximizes antimicrobial impact, and reduces the likelihood of emerging resistance on therapy. Adjunctive corticosteroid therapy has been shown to reduce morbidity and mortality in all but late stage disease.
Collapse
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Kutiyal AS, Gupta N, Garg S, Hira HS. A Study of Haematological and Haemostasis Parameters and Hypercoagulable State in Tuberculosis Patients in Northern India and the Outcome with Anti-Tubercular Therapy. J Clin Diagn Res 2017; 11:OC09-OC13. [PMID: 28384907 DOI: 10.7860/jcdr/2017/24022.9249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/19/2016] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Tuberculosis is one of the leading infectious diseases with high morbidity and mortality in the developing countries. Tuberculosis is also rarely associated with hypercoagulable state and very limited literature is available on this association. AIM To study the haematological and haemostasis laboratory parameters, to correlate the abnormalities for a hypercoagulable state and to study the outcome with anti-tubercular therapy. MATERIALS AND METHODS The study population included 128 patients with newly diagnosed tuberculosis. Anti-tubercular therapy naïve patients were studied for haemostasis parameters like Prothrombin time, Activated Partial Thromboplastin time, Factor VIII, Fibrinogen and D-dimer and haematological parameters like Haemoglobin, White Blood Cells, Platelet count, Erythrocyte Sedimentation Rate (ESR), Lactate Dehydrogenase, C-reactive protein and albumin. At the end of the second month of anti-tubercular therapy, results were compared and analysed using statistical package for the social sciences software (SPSS). RESULTS Prothrombin levels were deranged in 50%. Activated Partial Thromboplastin time levels were deranged in 18%. Deranged Factor VIII levels were found in 35.15%. Fibrinogen levels were deranged in 57%. D-Dimer positivity was found in 57.8% patients. Anaemia was found in 75.78%, Leukocytosis in 49.21%, Thrombocytopenia in 37.5% and Hypoalbuminaemia in 75%. ESR levels were raised in 98.43%. Follow up comparison analysis revealed significant p-value for all the parameters except Factor VIII and Activated Partial Thromboplastin time. Similar trend was also observed within different groups of Tuberculosis patients. CONCLUSION Tuberculosis does favour a hypercoagulable state with increased risk of developing thrombosis and significant improvement with the anti-tubercular treatment alone.
Collapse
Affiliation(s)
- Aditya Singh Kutiyal
- Senior Resident, Department of Internal Medicine, Maulana Azad Medical College , New Delhi, India
| | - Naresh Gupta
- Director- Professor, Department of Internal Medicine, Maulana Azad Medical College , New Delhi, India
| | - Sandeep Garg
- Professor, Department of Internal Medicine, Maulana Azad Medical College , New Delhi, India
| | - Harmanjit Singh Hira
- Director- Professor, Department of Internal Medicine, Maulana Azad Medical College , New Delhi, India
| |
Collapse
|
32
|
Tai MLS, Viswanathan S, Rahmat K, Nor HM, Kadir KAA, Goh KJ, Ramli N, Bakar FKA, Zain NRM, Yap JF, Ong BH, Rafia MH, Tan CT. Cerebral infarction pattern in tuberculous meningitis. Sci Rep 2016; 6:38802. [PMID: 27958312 PMCID: PMC5153843 DOI: 10.1038/srep38802] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 11/15/2016] [Indexed: 11/10/2022] Open
Abstract
Tuberculous meningitis (TBM) causes significant morbidity and mortality. The primary objective was to re-examine the concept of “TB zone” and “ischaemic zone” in cerebral infarction in patients with tuberculous meningitis. The secondary objective was to evaluate cerebral infarction, vasculitis and vasospasm in tuberculous meningitis infections. Between 2009 and 2014, TBM patients were recruited. Neuroimaging was performed and findings of cerebral infarction, vasculitis and vasospasm were recorded. Infarcts were classified based on arterial supply and Hsieh’s classification. Fifty-one TBM patients were recruited of whom 34 patients (67%) had cerebral infarction. Based on Hsieh’s classification, 20 patients (59%) had infarcts in both “TB zone” and “ischaemic zones”. 12 patients (35%) had infarcts in “ischaemic zone” and two (6%) patients had infarcts in “TB zone”. In terms of vascular supply, almost all patients (35/36) had infarcts involving perforators and cortical branches. 25 patients (73%) and 14 patients (41%) had infarcts supplied by lateral lenticulostriate and medial lenticulostriate arteries respectively. 15 patients (37%) had vasculitis. Vasospasm was present in six patients (15%). 29 patients (85%) with cerebral infarction also had leptomeningeal enhancement (p = 0.002). In summary, infarcts involved mainly perforators and cortical branches, rather than “TB zone” versus “ischaemic zone”.
Collapse
Affiliation(s)
- Mei-Ling Sharon Tai
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Shanthi Viswanathan
- Department of Neurology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Kartini Rahmat
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Hazman Mohd Nor
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Khairul Azmi Abdul Kadir
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Khean Jin Goh
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Norlisah Ramli
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Fatimah Kamila Abu Bakar
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | | | - Jun Fai Yap
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Beng Hooi Ong
- Department of Medicine, Hospital Alor Setar. Jalan Langgar, 05460 Alor Setar, Malaysia
| | - Mohd Hanip Rafia
- Department of Neurology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Chong Tin Tan
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| |
Collapse
|
33
|
Cerebral hemorrhage due to tuberculosis meningitis: a rare case report and literature review. Oncotarget 2016; 6:45005-9. [PMID: 26675758 PMCID: PMC4792608 DOI: 10.18632/oncotarget.6528] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/02/2015] [Indexed: 11/25/2022] Open
Abstract
Tuberculosis (TB) is a common disease to threaten human health. TB of the central nervous system (CNS) is rare but the most serious type of systemic TB because of its high mortality rate, serious neurological complications and sequelae. In this case report, we describe a woman who presented with walking instability, intracerebral hemorrhage and leptomeningeal enhancement due to tuberculosis meningitis. The patient had no significant medical history and the initial clinical symptoms were walking instability. On analysis, the cerebrospinal fluid was colorless and transparent, the pressure was more than 400 mm H2O, there was lymphocytic pleocytosis, increased protein, and decreased glucose levels present. No tuberculosis or other bacteria were detected. The patient's brain computed tomography image showed intra-cerebral hemorrhage (ICH) and contrast magnetic resonance imaging showed ICH in the right frontal lob, and leptomeningeal enhancement. CNS TB is rare but has a high mortality rate. As this disease has no unique characteristics at first presentation such as epidemiology and obvious clinical manifestation, a diagnosis of CNS TB remains difficult.
Collapse
|
34
|
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the main form of tuberculosis that affects the central nervous system and is associated with high rates of death and disability. Most international guidelines recommend longer antituberculous treatment (ATT) regimens for TBM than for pulmonary tuberculosis disease to prevent relapse. However, longer regimens are associated with poor adherence, which could contribute to increased relapse, development of drug resistance, and increased costs to patients and healthcare systems. OBJECTIVES To compare the effects of short-course (six months) regimens versus prolonged-course regimens for people with tuberculous meningitis (TBM). SEARCH METHODS We searched the following databases up to 31 March 2016: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; EMBASE; LILACS; INDMED; and the South Asian Database of Controlled Clinical Trials. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials. We also checked article reference lists and contacted researchers in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) and prospective cohort studies of adults and children with TBM treated with antituberculous regimens that included rifampicin for six months or longer than six months. The primary outcome was relapse, and included studies required a minimum of six months follow-up after completion of treatment. DATA COLLECTION AND ANALYSIS Two review authors (SJ and HR) independently assessed the literature search results for eligibility, and performed data extraction and 'Risk of bias' assessments of the included studies. We contacted study authors for additional information when necessary. Most data came from single arm cohort studies without a direct comparison so we pooled the findings for each group of cohorts and presented them separately using a complete-case analysis. We assessed the quality of the evidence narratively, as using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was inappropriate with no direct comparisons between short- and prolonged-course regimens. MAIN RESULTS Four RCTs and 12 prospective cohort studies met our inclusion criteria, and included a total of 1881 participants with TBM. None of the included RCTs directly compared six months versus longer regimens, so we analysed all data as individual cohorts to obtain relapse rates in each set of cohorts.We included seven cohorts of participants treated for six months, with a total of 458 participants. Three studies were conducted in Thailand, two in South Africa, and one each in Ecuador and Papua New Guinea between the 1980s and 2009. We included 12 cohorts of participants treated for longer than six months (ranging from eight to 16 months), with a total of 1423 participants. Four studies were conducted in India, three in Thailand and one each in China, South Africa, Romania, Turkey and Vietnam, between the late 1970s and 2011.The proportion of participants classified as having stage III disease (severe) was higher in the cohorts treated for six months (33.2% versus 16.9%), but the proportion with known concurrent HIV was higher in the cohorts treated for longer (0/458 versus 122/1423). Although there were variations in the treatment regimens, most cohorts received isoniazid, rifampicin, and pyrazinamide during the intensive phase.Investigators achieved follow-up beyond 18 months after completing treatment in three out of the seven cohorts treated for six months, and five out of the 12 cohorts treated for eight to 16 months. All studies had potential sources of bias in their estimation of the relapse rate, and comparisons between the cohorts could be confounded.Relapse was an uncommon event across both groups of cohorts (3/369 (0.8%) with six months treatment versus 7/915 (0.8%) with longer), with only one death attributed to relapse in each group.Overall, the proportion of participants who died was higher in the cohorts treated for longer than six months (447/1423 (31.4%) versus 58/458 (12.7%)). However, most deaths occurred during the first six months in both treatment cohorts, which suggested that the difference in death rate was not directly related to duration of ATT but was due to confounding. Clinical cure was higher in the group of cohorts treated for six months (408/458 (89.1%) versus longer than six months (984/1336 (73.7%)), consistent with the observations for deaths.Few participants defaulted from treatment with six months treatment (4/370 (1.1%)) versus longer treatment (8/355 (2.3%)), and adherence was not well reported. AUTHORS' CONCLUSIONS In all cohorts most deaths occurred in the first six months; and relapse was uncommon in all participants irrespective of the regimen. Further inferences are probably inappropriate given this is observational data and confounding is likely. These data are almost all from participants who are HIV-negative, and thus the inferences will not apply to the efficacy and safety of the six months regimens in HIV-positive people. Well-designed RCTs, or large prospective cohort studies, comparing six months with longer treatment regimens with long follow-up periods established at initiation of ATT are needed to resolve the uncertainty regarding the safety and efficacy of six months regimens for TBM.
Collapse
Affiliation(s)
- Sophie Jullien
- Jigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Hannah Ryan
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
| | - Manish Modi
- Postgraduate Institute of Medical Education and ResearchDepartment of NeurologyChandigarh 160 012India
| | - Rohit Bhatia
- All India Institute of Medical SciencesDepartment of NeurologyNew DelhiIndia110029
| | | |
Collapse
|
35
|
Chen YF, Wang DN, Chen ZT, Zhao ZH, Lin Y, Wang HY, Wang N. Risk factors associated with acute/subacute cerebral infarction in HIV-negative patients with cryptococcal meningitis. J Neurol Sci 2016; 364:19-23. [DOI: 10.1016/j.jns.2016.02.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 02/24/2016] [Accepted: 02/24/2016] [Indexed: 02/08/2023]
|
36
|
Gutierrez J, Katan M, Elkind MS. Collagen Vascular and Infectious Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00036-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
37
|
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.
Collapse
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
| |
Collapse
|
38
|
Youngblood LB, Dooley JW. Atypical cause of stroke in a 27 year old male. AMERICAN JOURNAL OF CASE REPORTS 2012; 13:75-8. [PMID: 23569494 PMCID: PMC3616049 DOI: 10.12659/ajcr.882774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 03/06/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Central nervous system (CNS) Tuberculosis (TB) meningitis is a progressive disease that can present in many forms. CNS TB is encountered frequently in areas of high prevalence of tuberculosis and dissemination is common, but TB meningitis is a disease that has a relatively low prevalence in North America. CASE REPORT 27 year-old African American male presented with complaints of headache, altered mental status (AMS), and seizure activity. He was found to have fever, encephalopathy, and leukocytosis. Work up of his AMS revealed cerebral spinal fluid (CSF) consistent with acute lymphocytic meningitis and magnetic resonance imaging (MRI) revealed right basilar meningeal enhancement with acute right basal ganglia infarction. Given the characteristic CSF and MRI finding for Tuberculosis (TB) a computed tomography (CT) of the chest was performed which revealed right upper lobe nodules with central cavitations. Biopsy results revealed Tuberculosis. The patient showed significant improvement once empiric tuberculosis therapy was begun. CONCLUSIONS CNS TB is a treatable disease that will be fatal if not recognized early. It is imperative to be aware of the key clinical features of TB meningitis, and maintain a high level of suspicion when dealing with CNS infection if the cause is unknown.
Collapse
Affiliation(s)
- Laura B. Youngblood
- Department of Internal Medicine, UT College of Medicine, Chattanooga, TN, U.S.A
| | | |
Collapse
|
39
|
Morioka H, Matsumoto S, Kojima E, Takada K, Iwata S, Okachi S. Paradoxical infarct in tuberculous meningitis: a case report. Intern Med 2012; 51:949-51. [PMID: 22504257 DOI: 10.2169/internalmedicine.51.6830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a case of 78-year-old woman with a 1-week history of fever and left hemiparesis. Head magnetic resonance imaging showed a small infarct. After admission, she showed altered consciousness and another small infarct. She finally had diagnoses of miliary tuberculosis (miliary-TB) and tuberculous meningitis (TBM). She recovered after receiving anti-tuberculous therapy (ATT) with prednisolone. However, 5 weeks later, we found another infarct. This is a rare case of TBM with recurrent infarcts in atypical lesions in spite of ATT. We suggest the possibility that the new infarct after ATT was due to a paradoxical reaction.
Collapse
Affiliation(s)
- Hiroshi Morioka
- Division of Infectious Disease, Tokyo Metropolitan Komagome Hospital, Japan.
| | | | | | | | | | | |
Collapse
|
40
|
Javaud N, Certal RDS, Stirnemann J, Morin AS, Chamouard JM, Augier A, Bouchaud O, Carpentier A, Dhote R, Dumas JL, Fantin B, Fain O. Tuberculous cerebral vasculitis: retrospective study of 10 cases. Eur J Intern Med 2011; 22:e99-104. [PMID: 22075322 DOI: 10.1016/j.ejim.2011.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 04/12/2011] [Accepted: 04/14/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tuberculous cerebral vasculitis is a complication of tuberculous meningitis. This study was undertaken to determine the epidemiological characteristics, context, diagnostic means and outcomes under treatment of tuberculous cerebral vasculitides. METHODS All consecutive patients diagnosed with tuberculous cerebral vasculitis were identified from the databases of three Internal Medicine, one Neurology and one Infectious Disease Departments in three suburban Parisian hospitals. RESULTS We describe 10 cases: five men and five women (median age 33.5 [range: 27-55] years). Two were infected with the human immunodeficiency virus. Nine patients had tuberculous meningitis, eight with extraneurological involvement. The following manifestations led to the diagnosis: motor deficit, acute confusional state, headaches, involvement, coma and/or seizures. The cerebral vasculitis revealed tuberculosis in three patients, but tuberculosis was already known when vasculitis was diagnosed for the seven others. The cerebral computed-tomography scan showed cerebral infarctions in five patients, hydrocephalus and tuberculomas in four, while magnetic resonance imaging detected infarctions and leptomeningitis in nine patients, pachymeningitis in one, hydrocephalus and tuberculomas in seven. Therapy combined antituberculous agents with oral corticosteroids for all patients, preceded by a methylprednisolone pulse for five patients. Outcome was favorable for nine patients. CONCLUSION We described the non-negligible frequency of tuberculous cerebral vasculitides, their clinical manifestations and their potential severity, and the diagnostic and monitoring contributions of magnetic resonance imaging and magnetic resonance angiography.
Collapse
MESH Headings
- Adult
- Databases, Factual/statistics & numerical data
- Female
- Humans
- Magnetic Resonance Angiography
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Retrospective Studies
- Tuberculosis, Lymph Node/cerebrospinal fluid
- Tuberculosis, Lymph Node/epidemiology
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/epidemiology
- Tuberculosis, Meningeal/pathology
- Tuberculosis, Pulmonary/cerebrospinal fluid
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Splenic/cerebrospinal fluid
- Tuberculosis, Splenic/epidemiology
- Vasculitis, Central Nervous System/epidemiology
- Vasculitis, Central Nervous System/microbiology
- Vasculitis, Central Nervous System/pathology
Collapse
Affiliation(s)
- Nicolas Javaud
- Service des Urgences, Hôpital Jean-Verdier, Assistance Publique-Hôpitaux de Paris, Université Paris 13, Bondy Cedex, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Radwan W, Sawaya R. Intracranial haemorrhage associated with cerebral infections: A review. ACTA ACUST UNITED AC 2011; 43:675-82. [DOI: 10.3109/00365548.2011.581304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
42
|
Misra UK, Kalita J, Maurya PK. Stroke in tuberculous meningitis. J Neurol Sci 2011; 303:22-30. [DOI: 10.1016/j.jns.2010.12.015] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 12/20/2010] [Accepted: 12/20/2010] [Indexed: 11/26/2022]
|
43
|
Chen SF, Lu CH, Lui CC, Huang CR, Chuang YC, Tan TY, Tsai NW, Chang CC, Tsai WC, Chang WN. Acute/subacute cerebral infarction (ASCI) in HIV-negative adults with cryptococcal meningoencephalitis (CM): a MRI-based follow-up study and a clinical comparison to HIV-negative CM adults without ASCI. BMC Neurol 2011; 11:12. [PMID: 21269442 PMCID: PMC3037868 DOI: 10.1186/1471-2377-11-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Accepted: 01/26/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Acute/subacute cerebral infarction (ASCI) in HIV-negative cryptococcal meningoencephalitis (CM) adults has rarely been examined by a series of MRI-based follow-up study. We studied a series of MRI follow-up study of CM adults and compared the clinical characters of those with ASCI and those without ASCI. METHODS The clinical characteristics and a series of brain MRI findings of seven CM adults with ASCI were enrolled for analysis. The clinical characteristics of another 30 HIV-negative CM adults who did not have ASCI were also included for a comparative analysis. RESULTS The seven HIV-negative CM adults with ASCI were four men and three women, aged 46-78 years. Lacunar infarction was the type of ASCI, and 86% (6/7) of the ACSI were multiple infarctions distributed in both the anterior and posterior cerebrovascular territories. The seven CM patients with ASCI were significantly older and had a higher rate of DM and previous stroke than the other 30 CM adults without ASCI. They also had a higher incidence of consciousness disturbance at presentation and had a poor prognosis. CONCLUSION ASCI was found in 18.9% (7/37) of HIV-negative CM adults. Serial MRI follow-up studies may allow a better delineation of ASCI in this specific group of infectious disease and multiple lacunar infarctions was the most common type. Older in age and presence of DM and previous stroke were the significant underlying conditions. CM patients with ASCI also had a poor therapeutic outcome.
Collapse
Affiliation(s)
- Shu-Fang Chen
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Cheng-Hsien Lu
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Chun-Chung Lui
- Department of Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Chi-Ren Huang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Yao-Chung Chuang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Teng-Yeow Tan
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Nai-Wen Tsai
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Chiung-Chih Chang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Wan-Chen Tsai
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| | - Wen-Neng Chang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung 833, Taiwan
| |
Collapse
|
44
|
Anderson N, Somaratne J, Mason D, Holland D, Thomas M. Neurological and systemic complications of tuberculous meningitis and its treatment at Auckland City Hospital, New Zealand. J Clin Neurosci 2010; 17:1114-8. [DOI: 10.1016/j.jocn.2010.01.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 01/03/2010] [Indexed: 02/08/2023]
|
45
|
Anuradha HK, Garg RK, Agarwal A, Sinha MK, Verma R, Singh MK, Shukla R. Predictors of stroke in patients of tuberculous meningitis and its effect on the outcome. QJM 2010; 103:671-8. [PMID: 20587540 DOI: 10.1093/qjmed/hcq103] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stroke is a devastating complication of tuberculous meningitis and is an important determinant of its outcome. AIM To prospectively evaluate the predictive factors for stroke in patients with tuberculous meningitis and to assess the impact of stroke on the overall prognosis and outcome. METHODS We evaluated and followed 100 patients of tuberculous meningitis for 6 months. Magnetic resonance imaging was performed at inclusion and after 6 months. We evaluated the predictors of stroke and also assessed the effect of stroke on the outcome. Outcome was defined with the help of modified Rankin scale. RESULTS Of the 100 patients, 6 lost to follow-up. Thirty patients had stroke, 27 of them had stroke at inclusion. Three patients developed stroke during follow-up. In most of the patients, stroke was a manifestation of advanced stages of tuberculous meningitis. Internal capsule/basal ganglia were the most frequently involved sites. Infarcts commonly involved the middle cerebral arterial territory. On univariate analysis, predictors of stroke were aged >25 years (P < 0.001), cranial nerve involvement (P < 0.001), sylvian fissure exudates (P = 0.026), posterior fossa exudates (P = 0.016), optic chiasmal exudates (P = 0.04) and vision impairment (P = 0.004). Stage III tuberculous meningitis (P < 0.001) was also a predictor of stroke. On multivariate analysis aged >25 years was found a significant predictor of stroke. Strokes in patients with tuberculous meningitis were associated with poor prognosis. CONCLUSION Stroke occurred in 30% of cases with tuberculous meningitis. Advanced stage of tuberculous meningitis, basal exudates, optochiasmatic arachnoiditis and vision impairment were significant predictors of stroke. Stroke independently predicted the poor outcome of tuberculous meningitis.
Collapse
Affiliation(s)
- H K Anuradha
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow 226 003, UP, India
| | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
Tuberculous meningitis is a severe form of extrapulmonary tuberculosis. The exact incidence and prevalence are not known. In countries with high burden of pulmonary tuberculosis, the incidence is expected to be proportionately high. Children are much more vulnerable. Human immunodeficiency virus-infected patients have a high incidence of tuberculous meningitis. The hallmark pathological processes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Headache, vomiting, meningeal signs, focal deficits, vision loss, cranial nerve palsies and raised intracranial pressure are dominant clinical features. Diagnosis is based on the characteristic clinical picture, neuroimaging abnormalities and cerebrospinal fluid changes (increased protein, low glucose and mononuclear cell pleocytosis). Cerebrospinal fluid smear examination, mycobacterial culture or polymerase chain reaction is mandatory for bacteriological confirmation. The mortality and morbidity of tuberculous meningitis are exceptionally high. Prompt diagnosis and early treatment are crucial. Decision to start antituberculous treatment is often empirical. WHO guidelines recommend a 6 months course of antituberculous treatment; however, other guidelines recommend a prolonged treatment extended to 9 or 12 months. Corticosteroids reduce the number of deaths. Resistance to antituberculous drugs is associated with a high mortality. Patients with hydrocephalus may need ventriculo-peritoneal shunting. Bacillus Calmette-Guérin vaccination protects to some degree against tuberculous meningitis in children.
Collapse
Affiliation(s)
- R K Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh, Lucknow, India.
| |
Collapse
|
47
|
Misch M, Thomale UW, Keitzer R, Vajkoczy P. Prevention of secondary ischemic events by superficial temporal artery-middle cerebral artery bypass surgery after tuberculosis-induced vasculopathy in a 5-year-old child. J Neurosurg Pediatr 2010; 6:69-72. [PMID: 20593990 DOI: 10.3171/2010.4.peds09411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Tuberculosis-related vasculopathy and resulting ischemic events are a common finding after tuberculous meningitis (TBM) in children. The authors report on a case of recurring ischemic episodes that were refractory to repetitive endovascular procedures (transluminal angioplasty, stent insertion, in-stent vessel dilation). After failure of endovascular treatment, extracranial-intracranial (EC-IC) bypass surgery was performed to prevent further ischemia. This 5-year-old girl presented with a series of ischemic events in the left middle cerebral artery (MCA) territory 12 months after her presentation with TBM. Angiography studies showed a 50% lumen reduction of the left MCA. After failure of antithrombocyte aggregation and repeated endovascular procedures to prevent new ischemia, EC-IC bypass surgery was performed. The left superficial temporal artery-MCA bypass was found to be capable of preventing new ischemic events in the 21-month follow-up period, despite a near-total MCA occlusion on follow-up conventional and MR angiography studies. Bypass surgery seems to be a reliable tool to augment cerebral blood flow in tuberculosis-related stenoocclusive changes of cerebral vasculature after the failure of endovascular procedures.
Collapse
Affiliation(s)
- Martin Misch
- Department of Neurosurgery, Charité Campus Virchow, Medical University of Berlin, Berlin, Germany.
| | | | | | | |
Collapse
|
48
|
Schoeman JF, Andronikou S, Stefan DC, Freeman N, van Toorn R. Tuberculous meningitis-related optic neuritis: recovery of vision with thalidomide in 4 consecutive cases. J Child Neurol 2010; 25:822-8. [PMID: 20519667 DOI: 10.1177/0883073809350507] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Blindness is an uncommon but devastating complication of tuberculosis meningitis. The main causes are chronically raised intracranial pressure (hydrocephalus and/or tuberculomas) or direct involvement of the optic chiasm or optic nerves by the basal arachnoiditis (inflammation and/or compression). Antituberculosis therapy combined with corticosteroids and control of intracranial pressure constitutes the mainstay of therapy for tuberculous meningitis. Despite these treatment measures, some patients develop blindness, mainly as a result of progressive optochiasmatic arachnoiditis. This led us to explore the role of adjuvant thalidomide therapy, and we describe the dramatic recovery of vision in 4 consecutive cases. Clinical recovery was accompanied by marked radiological improvement on magnetic resonance imaging (MRI) of the brain.
Collapse
Affiliation(s)
- Johan F Schoeman
- Department of Pediatrics and Child Health, Tygerberg Children's Hospital, Faculty of Health Sciences, University of Stellenbosch, Western Cape, South Africa.
| | | | | | | | | |
Collapse
|
49
|
Misra U, Kalita J, Nair P. Role of aspirin in tuberculous meningitis: A randomized open label placebo controlled trial. J Neurol Sci 2010; 293:12-7. [DOI: 10.1016/j.jns.2010.03.025] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 03/22/2010] [Accepted: 03/24/2010] [Indexed: 10/19/2022]
|
50
|
Sheu JJ, Hsu CY, Yuan RY, Yang CC. Clinical characteristics and treatment delay of cerebral infarction in tuberculous meningitis. Intern Med J 2010; 42:294-300. [PMID: 20492009 DOI: 10.1111/j.1445-5994.2010.02256.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebral infarction (CI) complicating tuberculous meningitis (TBM) is a major risk factor of permanent disability. The prevention of this complication is an important issue in the quality care of TBM patients. AIM Our aim was to evaluate the clinical characteristics of TBM patients with CI. METHODS Ninety-one adult patients with TBM were studied between 1999 and 2007. Clinical, neuroradiological and cerebrospinal fluid data of patients with CI were compared with those without CI. RESULTS Thirty of the 91 patients had CI, including symptomatic CI occurring before admission in 10 patients, symptomatic CI occurring during hospitalisation in four and silent CI in 16 patients. When compared with non-CI patients, patients with CI were younger and associated with focal weakness on presentation, and had basal meningeal enhancement and hydrocephalus on brain images. Prolonged doctor delays of antituberculosis and steroid therapies, neurosurgical intervention, focal weakness and dementia as sequelae, and poor outcomes were associated with patients with CI than non-CI patients. CONCLUSION Contrast-enhanced brain imaging is helpful to explore the basal meningeal enhancement in CI patients, and contributes to early diagnosis and treatment of TBM. Early antituberculosis and steroid therapies may help prevent CI in TBM patients.
Collapse
Affiliation(s)
- J-J Sheu
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan.
| | | | | | | |
Collapse
|