Giant Cerebral Tuberculoma Masquerading as Malignant Brain Tumor - A Report of Two Cases

Magnetic Resonance Imaging Appearance of Giant Intracerebral Tuberculoma: A Retrospective Analysis

Background: Giant intracerebral tuberculomas are rare lesions but should be considered in the differential diagnosis of intracranial space-occupying lesion in an endemic region.Objective: The purpose of this study is to analyze the clinical data and magnetic resonance imaging (MRI) findings of giant intracerebral tuberculomas to improve the diagnostic precision.Material and Methods: The clinical and MRI findings of 22 patients of giant intracerebral tuberculoma were analyzed retrospectively. For the statistical analysis independent sample Student t-test was used.Results: For 22 patients included in this sample the giant intracerebral tuberculoma was of size more than 2.5cm. The majority of the giant tuberculomas (19 patients (86.4%))was located in the supratentorial area.T2-weighted hypointense core of giant tuberculoma was observed in 12 patients (54.5%) and T1 hyperintensities were observed in peripheral (wall) of the giant tuberculoma in 14 patients (63.6%). The mean ADC value of the peripheral (wall) of the giant tuberculoma was 1.034± 0.466[SD] x 10-3mm2/s and the core was 0.994± 0.455[SD] x 10-3mm2/s with a statistically significant difference (p-value <0.0005) in between. MR spectroscopy showed raised lipid peak at 0.9 to 1.33 ppm in 10 patients (45.5%),raised lipid-lactate peak in 12 patients (54.5%),raised Choline/Cr ratio more than 1.2 in 14 patients(63.6%) and Choline/Cr ratio less than 1.2 in 5 patients (22.7%). Associated involvement of lung was observed in the 6patients (27.3%), cervical lymph node in 1 patient (4.5%) and spine in 1patient (4.5%).Conclusions: MRI plays a vital role in distinguishing giant intracerebral tuberculomas from other intracranial space-occupying lesions, thereby allows the early institution of anti-tubercular treatment (ATT), decreased patient morbidity, mortality, and prevents unnecessary neurosurgical excision.

Tumour-like presentation of brainstem tuberculoma: a lesson learnt

Brainstem tuberculoma is diagnostically challenging as it lacks clinical clues and imaging mimics a high-grade glioma (HGG). We report the case of an adolescent girl diagnosed with brainstem HGG, who was referred to our centre for Gamma Knife. Initial MRI showed a pontomedullary junction, ring-enhancing lobulated lesion demonstrating distinct central hypointensity on T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) images with extensive vasogenic oedema. An alternative diagnosis of infection was entertained, and biopsy was suggested; however, the parents opted for a trial of alternative treatment. Suboccipital craniotomy and debulking were only performed 3 months later when her symptoms worsened, and MRI revealed enlargement of the lesion. A cheesy 'tumour' was noted intraoperatively; histopathological findings later confirmed chronic granulomatous inflammation. In an endemic area, a high index of suspicion of a tuberculoma is vital specifically in the presence of central T2W/FLAIR hypointensity of a ring-enhancing lesion.