cns tbc imaging

7/25/2019 Cns Tbc Imaging

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surgery

Moderators

Dr Ashish Suri

Dr Dee ak Gu ta

Dr Ajay Bisht


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TuberculosisAs old as recorded history

Symptoms described in the Rig Veda (1500 BC)

Unequivocal lesions in Egyptian mummies

Odier, Ford described meningeal TB 1790

urg ca exc s on ern c e an a n 1882,3/11/2010 CNS tuberculosis imaging and surgery 2


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Tuberculosis CNS tuberculosis complicates 10% of all TB

ever t e rst man estat on

ccurs w n 12 mon s

rc e o s more requen y nvo ve an ebasilar system

3/11/2010 CNS tuberculosis imaging and surgery 3


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Mycobacterium tuberculosisAcid fast bacillus

Does not stain on gramsta n

Obligate aerobes cu o grow

High lipid in cell wall

om n s ov ne v um

3/11/2010CNS tuberculosis imaging and surgery

4


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Pathogenesis May develop during initial infection/ reactivation

Haematogenous dissemination

Commonest

Rupture of focus into subarachnoid/ ventricular space

Contiguous spread



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CNS tuberculosis Intracranial

Parenchymal

en ngea

Osseous

S inal Parenchymal

Meningeal

Arac noi itis

Osseous



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Epidemiology Incidence varies blacks > whites

Predominantly in theyoung (50%


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Pathology Immature lesions multiple tubercles in oedematous

brain

Mature: avascular mass, nodular extensions, yellowish



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Pathology (parrenchymal) Can be present anywhere

Cerebellum in children

Cerebral hemisphere and basal ganglia commoner inadults



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Pathology (tuberculoma) Tuberculoma ( classical lesion)

Tuberculoma en plaque

Tuberculous abscess

Cystic tuberculoma Multiple grape like tuberculoma

Microtuberculoma

Calcified tuberculoma

Tuberculous encephalopathy



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Pathology (tuberculoma) Dastur described six main types

Parenchymal changes.

(1) Ventriculitis

(2) Borderzone encephalitis

3 n arct on

(4) Internal hydrocephalus

(5) Diffuse oedema

6 Tu ercu oma



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Pathology (meningeal) Classically Commonest in 6m 3 years

Now adults 50%

Thick exudate encasing nerves, vessels

HCP, tuberculoma, arachnoiditis Diffuse perivasculitis

Infarcts

Pachymeningitis



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Diagnosis Montoux test

Hb/ ESR

CXR

ELISA CSF

PCR

Imaging

Biopsy



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ImagingX ray

Angiography of historical significance

CT

MRI



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Imaging Tuberculoma

Typically cortical and subcortical

u p e n 1035

Milliary rare ( children)

Menin itis commonest form of CNS TB Isolated meningitis is rare (5% in children)

Basal cisterns



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Imaging (CT tuberculoma) Cerebritis: hypodense areas

Perilesional oedema out of proportion ,

enhancement

Evolved : well delineated ring enhancing mass, target signcentra en ancement or ca c cat on

Healed: often calcify

Manifestations Small disc/ rings

Large rings with central lucency

Lar e nodular mass with irre ular outline

Multiple lesions in 1520%



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Caseating tuberculosis granulomainvolving the left temporal lobe.CECT shows a rim-enhancinglesion in the left temporal lobe


consistent with a caseatingtuberculosis granuloma


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Imaging (MRI tuberculoma) T1 : isointence

T2: central hyper with hypo ring

Marked thin rim enhancement

Hypo on T2: fibrosis, gliosis, macrophage infiltration



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Parrenchymal tuberculosis. contrast-enhanced T1-

weighted MR image demonstrates multiple

enhancing caseating and non-caseating


,

and parietal lobes


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Milliary CNS tuberculosis. Axial contrast-enhanced T1-


weighted MR image shows multiple small high-signal-intensity foci within both cerebral hemispheres


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3/11/2010 CNS tuberculosis imaging and surgery22


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(a) Sagittal T2- hyperintensity in the cervical spinal cord extending from C2 to C7. Ahypointense nodule representing the granuloma is noted at the C4 level.(b) Sagittal T1 & (c) axial T1- with fat suppression after contrast reveal an area of


-

the spinal cord. A smaller enhancing granuloma is also noted at the C2 level on thesagittal image


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MRS

decrease in NAA/Cr

slight decrease in NAA/Cho

-



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A. Bernaerts, F. M. VanhoenackerTuberculosis of the central nervous system: overview of

neuroradiological findings. Eur Radiol (2003) 13:18761890



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Imaging (meningitis)Active

Sequelae

Hydrocephalus

Ischemia and infarction e a en cu os r a e 75

Thalamoperforating

Cortex 25%

Bilateral 70%

Atrophy



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Imaging (CT meningitis) NCCT:

scans may be normal Obliteration of basal cisterns by hypo/ iso dense exudate

en p aque ura t c en ng Popcorn calcification

Hydrocephalus

Infarcts

CECT: Abnormal meningeal enhancement (may persist) Leptomeningeal enhancement sylvian fissures, tentorium Granulomas in the basal meninges

Ependymitis



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Imaging (MRI meningitis) Unenhanced scan: does not show active meningitis

Spine

CSF ocu ations

Obliteration of arachnoid space

Loss of cord outline in cervicodorsal cord

Thickening and clumping of roots in the lumbar cord

Contrast T1 : basal meningeal enhancement

spine

Linear enhancement of cord/ roots



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Tuberculous meningitis. Axial contrast-enhanced

T1-weighted magnetic resonance (MR) image

shows florid meningeal enhancement that is mostpronounced within the basal cisterns



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Tubercular meningitis. Axial FLAIR-MR]s ow ng mar e yper n ens y o e asacisterns and prominent temporal horns in apatient with mild communicatinghydrocephalus



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Caseating dural /epidural tuberculosis granuloma orabscess

-

b) Axial T1 contrast- dural/epidural rim enhancement suggestive of caseating tuberculosisgranuloma or abscess.


c ag tta en ance - t e caseat ng ura ep ura tu ercu os s granu oma or a scess

posterior to the clivus. Abnormal meningeal enhancement is present


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Spinal tuberculous meningitis. Sagittal gadolinium-

enhanced T1-weighted MR image of the thoracic spine


demonstrates irregular, linear, nodular meningealenhancement


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Enhanced T1-weighted magnetic resonance imaging with fat suppression show intense



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Tu ercu ous pac ymeningitis Rare

Common sites of involvement are cavernous sinus, floor of

middle cranial fossa and tentorium.

CT

hyperattenuating solid plaque like densitiesca ci ication may e seen

MRI

T1 : h o intense thickened duramater. T2 : hypo intense thickened meninges.

T1 C+ (GAD) : intense homogenous enhancement of thickenedmeninges.



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Management Medical therapy

Surgery

indications s on or e t reatene y mass e ect

Failure of response to medical therapy

Paradoxical increase in lesion size with therapy Diagnosis in doubt



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WHO recommendations


WHO Treatment of tuberculosis: guidelines 4th ed.


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ura on o rea men6 months

van Loenhout-Rooyackers JH, Keyser A, Laheij RJ, Verbeek AL, van der Meer JW.

Tuberculous meningitis: Is a 6-month treatment regimen sufficient? Int J Tuberc Lung Dis2001;5:128-35.

12 months

, . , .

Neurol 2005;4:160-70

18 months or Longer

Santosh Isac Poonnoose Vedantam Rajashekhar: Rate of Resolution of histologically

verified intracranial tuderculomas. Neurosurgery 53:873-879 2003



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Treatment

Rate of radiological resolution of intracranial tuberculoma

Series duration of ATT residual lesions %

Wang 1996 (16) 6 20

Awada 1998 (2) 12 0Poonnoose 2003 (28) 18 69.2

Santosh Isac Poonnoose, Vedantam Rajashekhar: Rate of Resolution ofhistologically verified intracranial tuderculomas. Neurosurgery 53:873-879,



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Medical management 4 rugs x 34 mont s

2 drugs x 1416 months occasionally longer

Most resolve in 1214 monthsR Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of thenervous s stem. Schmidek and Sweet o erative neurosur ical techni ues th edition16171631

AED to continue

Steroids in all irrespective of age and stage

Prasad K, Singh MB. Corticosteroids for managing tuberculous meningitis.


Cochrane Database Syst Rev 2008;1:CD002244.


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Resistant tuberculosis MDR : resistant to INH and Rifampicin

EDR/ XDR : MDR + resistance to Quinolones andinjecta e secon ine rugs



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Surgery Severe elevation of ICP

Threatening life or vision

Do not respond to drugs clinically/ radiologically

Diagnosis in doubt

Obstructive hydrocephalusR Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of the nervoussystem. Schmidek and Sweet operative neurosurgical techniques 5th edition; 16171631

m agnos s re eve pressure



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Surgical management Biopsy of the mass lesion

Hydrocephalus Communicating (commoner)

Non communicating



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Surgery principles Non eloquent areas total excision (small lesion)

Subtotal/ partial excision (large lesion/ eloquentcortex

Conservative excision around vital structures vacuat on o centra qu act ve port on n eep

seated lesions

R Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of the

nervous system. Schmidek and Sweet operative neurosurgical techniques 5th edition; 16171631

y rocep a us3/11/2010 CNS tuberculosis imaging and surgery 47


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MRC Grading for hydrocephalus



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Vellore grading Modified Vellore grading

Mathew JM, Rajshekhar V, Chandy MJ. Shunt surgery for poor grade patients with tuberculous meningitis

and hydrocephalus: Effect of response to external ventricular drainage and other factors on long-term

, , , , .tubercular meningitis: A long-term follow-up study. J Neurosurg 1991;74:64-9


outcome. J Neurol Neurosurg Psychiatry 1998;65:115-8


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Rajshekhar V. Management of hydrocephalus in patients


with tuberculous meningitis. Neurol India 2009;57:368-74


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Hydrocephalus Inevitable in those who survive 46 weeks

Mortality 20100%

Grade at admission significant

Early shunt for grade I,II



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ETV 73.1% success rate for ETV in TBM with hydrocephalus

A chugh, M hussain et al. Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic thirdventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy: J

Neurosurg Pediatrics 3:000000, 2009

Endovascular revascularization for ischemia

STA MCA bypass

be capable of preventing new ischemic events in the 21monthfollowup period Martin misch, Ultrich wilhelm et al. Prevention of secondary ischemic events by superficial temporal

arterymiddle cerebral artery bypass surgery after tuberculosisinduced vasculopathy in a 5yearold

child:Neurosurg Pediatrics 6:000000, 2010



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SUPRATENTORIAL 78

PARIETAL 28

FRONTAL 26TEMPORAL 1

BG / THALAMUS 4

SELAR/SUPRASELLAR 4

INFRATENTORIAL 50

CEREBELLUM 44

CP ANGLE 3

TENTORIUM 1



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cns tbc imaging

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