Original Article
Volume 5, No.1
April 2001
 Mohamed Maftah
 Ali Akhaddar
 M Lmejjati
 A Mansouri
 Najia El Abbadi
 Fouad Bellakhdar
 Department of Neurosurgery
 Avicenne Teaching Hospital
 Rabat
 Morocco
 Correspondence:
 Dr. Mohamed Maftah
 34, Rue Oued Ziz
 Appt 7 Agdal, Rabat
 Morocco
  Intracerebral tuberculoma - Report of 115 cases
 
   ABSTRACT

Cerebromeningeal tuberculosis is frequent in countries with endemic tuberculosis. The authors report 115 cases of intracerebral tuberculoma. The average age of the patients was 26 years. The analysis of 115 cases, reinforced by a literature review on the question, indicates the clear clinical heterogeneity of this affection. We insist upon the usefulness of medical imaging in the diagnosis of tuberculoma, as well as in the supervision of its therapeutic management. (p20-24)

Keywords: Tuberculosis and intracerebral tuberculoma.

INTRODUCTION

Tuberculosis is still very common in developing countries. In all countries it is especially seen in immunosuppressed patients.14,16,18,24 Although pulmonary localisation is predominant, cerebral tuberculosis is not rare. The tuberculoma is the second most encountered manifestation of central nervous system (CNS) tuberculosis after tuberculous meningitis. It affects mainly the population under 30 years of age.24 The treatment is medical in most cases, whereas surgical management is reserved for severe cases or when the diagnosis is uncertain.1,12,16
MATERIALS AND METHODS

115 cases of cerebral tuberculoma were treated in our department between 1986 and 1996. The series of 115 patients comprised of 64 women and 51 men, whose age ranging from 13 to 60 years (mean of 26 years). Symptom duration before treatment was from 3 weeks to 2 years (mean of 8 months). Intracranial hypertension is the most frequent reason of consultation (50 cases). Ophthalmologic symptoms were encountered in 34 patients, 19 of them had total blindness or light perception only and remaining 15 had poor vision. Fundoscopic examination, achieved in 80 patients, has shown an optic nerve atrophy in 15 cases, papillary oedema in 35 cases, and no abnormality in 30 cases.

Physical examination showed focal signs in 95 cases: 16 had hemiplegia, 29 hemiparesis, 1 monoplegia, 5 aphasis, 22 cranial nerves lesions, and 22 cerebellar syndrome. Epilepsy is noted in 27 cases. Poor general state is found in 9 cases. The tuberculoma is found in conjunction with pulmonary tuberculosis, 12 cases, lymph node tuberculosis 2 cases and vertebral tuberculosis 6 cases.

Contamination by family members was established in only 11 cases.

Laboratory studies: Anaemia is found in 20 patients. From 37 tuberculin skin tests carried out, 26 were positive. Mycobacterium tuberculosis was isolated in only one systematic sputum culture.

Radiological findings: Skull x-rays were obtained in all patients and showed signs of intracranial pressure in 31 patients: an enlarged sella in 11 cases, and digitiforms impressions in 20 cases.

A computed tomography (CT) scan (Fig. 1a and 2) carried out in 98 patients, was complemented by magnetic resonance imaging (MRI) (Fig. 1b) in 6 patients, and showed the presence of 66 supra-tentorial tuberculomas, 7 of which had multiple locations, and 49 were infratentorial, 11 of which were located in the brainstem. Hydrocephalus was found in 14 cases. Extracerebral localisation of tuberculosis was found in 16 patients, 10 had tuberculous cavity, 4 had mediastinal lymph node and 2 had miliary tuberculosis.

Neuropathological examination of all patients operated, by excision or biopsy revealed area of caseous necrosis surrounded by inflammatory granulation tissue containing many granuloma (epitheloid and giant cells) with scattered giant cells in all cases. Acid fast bacilli were found in only 4 cases.

Medical: It consisted of tuberculous chemotherapy, corticosteroids and phenobarbital in all patients, including those with infratentorial tuberculoma. This treatment was undertaken in only 19 patients and comprised rifampicin, isoniazid, pyrazinamide for 2 months, followed by 10 months of rifampicin and isoniazid.

Surgical: Surgical treatment was recommended in 96 patients for diagnostic and therapeutic reasons.

Three approaches were used:

1. Cerebrospinal fluid diversion, when intracranial pressure was significant in 14 cases: followed by surgical removal in 8 cases.
2. Tuberculoma excision: total in 34 cases and partial in 23 cases.
3. Biopsy: open biopsy in 20 cases and stereotaxic biopsy in 5 cases.
 
A
  
B
  
         
  Figure 1 – a) Axial CT-scan showing a tuberculoma of the left thalamic region. b) MRI: Sagittal T1-weighted image showing a large thalamic tuberculoma with brainstem extension.


Figure 2









  
  Figure 2 – Axial CT-scan showing multiple cerebellar tuberculomas. The fourth ventricle was compressed with obstructive hydrocephalus.
  
RESULTS

Twelve deaths (7 patients were operated and 5 were not) were recorded in our series, which means a mortality rate of about 10.4%. Three patients died after tuberculous meningitis, two cases of miliary tuberculosis, two patients after antituberculous drugs were discontinued by the patient. One patient with cardiovascular disease. The cause of death was unknown in one case. One patient with a sudden deterioration in neurologic status that was associated with paradoxical expansion of a cerebellar tuberculoma.

Clinical follow-up was 1 year on average for medically treated patients, and 15 months for operated patients. The clinical outcome (Table 1) was marked by cerebellar syndrome regression in 73% of the surgically managed patients and in 27% of the medically treated patients. Improvement of vision was seen in 50% of the medically treated patients and 27% of the operated ones. Regression of neurologic deficit occurred in 50% of the medically treated patients and 30% of operated patients.

Recurrence was seen in five patients, who discontinued antituberculous therapy after a good evolution. A good result was seen after the anti-tuberculous drugs were restarted.

DISCUSSION

The frequency of CNS tuberculoma is closely related to tuberculous endemic, which is still high in developing countries. In India, 20% of intracranial processes are tuberculomas;4 this number reaches 47% if only children under 15 are considered. In Europe, tuberculomas represents only 0.15% of intracranial processes.3,12 This percentage is increasing because of HIV infection.14,22 Lecuit in 1994 reports the incidence of 10% of intracranial tuberculoma in tuberculous HIV patients, mainly when tuberculous meningitis coexists.18 In HIV negative patients, tuberculoma is the only expression of cerebral tuberculosis in 60% of cases.8

Pathologically, tuberculoma is characterised by multiple confluent epitheloid granulomas with large areas of caseating necrosis and numerous Langerhan’s giant cells. On Ziehl-Nielsen stain, tubercule bacillus was rarely detected.

Tuberculoma is characterised by its clinical heterogeneity, which particularly depends on the variable location, size and number of the tuberculomas. Lisa and Deangelis emphasise the high frequency of seizures (50% - 80%), but intracranial hypertension or neurologic deficit can also be seen.20 No obvious clinical symptoms of extra-cerebral tuberculosis were found in 40% of cases.24

The tuberculin test is positive in 25% of patients only, chest x-ray is of normal aspect in 50% (16% in our series), and cerebrospinal fluid analysis are normal in 70% of cases.19

The CT scan is the most important examination.16 It shows supratentorial lesions more often than infratentorial ones.9,23

The centre of lesion is spontaneously hyper-, iso-, or hypodense, surrounded by an oedematous peripheral zone. Macroscopic calcifications can invariably be seen according to the stage of the lesions. MRI has better sensitivity for small lesion screening as it specifies their morphology and their location, owing to its three dimensional images.13 However, it does not show any specific lesions.

The radiological differential diagnosis includes a number of intracranial space-occupying lesions. Cerebral tuberculomas can be mistaken for abscesses, mycotic granulomas, parasitic cysts, primary (gliomas and lymphomas) or metastatic tumors.

The treatment of cerebral tuberculoma is becoming more conservative. It combines three antituberculous antibiotics. The addition of fluoroquinolones may be of interest.5,25 We emphasise the efficiency of steroids in reducing the perilesional oedema and threatening intracranial hypertension.1,2,17,21 Anticonvulsant treatment is mandatory for seizure control. The indication of medical treatment alone is justified because it is safe, efficient, and cheap.

It has to be attempted first in all cases with strict CT scan and MRI follow-up.11

Finally, medical management is obviously indicated when surgical treatment is impossible, because of the location, the multiplicity of lesions, or the severely altered general condition of the patient.1 Surgical treatment is currently suitable in cases of threatening intracranial hypertension, or rarely for diagnostic purposes.12,16

Some authors operate on the chronic cases and the calcified tuberculomas because they are resistant to medical treatment.10,15

Stereotaxic biopsy can be complicated by meningeal contamination.8 However it seems important for deeply localised tuberculomas, multiple lesions, and brainstem tuberculomas. It is useful for diagnostic confirmation before establishing medical treatment.

The prognosis is currently quite good; the post-operative mortality is estimated at 16%.6,21 In medically managed patients, the mortality is difficult to determine because of the absence of large series. This disease, however, is considered severe, because of the important complications it can cause. These complications recover in 5 to 60% of cases in some series.14,17

CONCLUSION

Tuberculosis and cerebral tuberculoma are still frequent in our country. The diagnosis is based on a group of arguments, clinical, epidemiological and neuroradiologic. The treatment is becoming increasingly medical but surgery is still indicated in cases of dangerous intracranial pressure or for diagnostic confirmation. Stereotaxic biopsy can be diagnostic in cases of multiples lesions, deep tuberculomas or brainstem lesions.

REFERENCES

1. Akhaddar A, Bourazza A, El Mostarchid B, Rouimi A, Ouahabi H, Mossedaq R: Tuberculomes du tronc cerebral. Deux case. Rev Neurol (Paris) 2000, 156: 399-402
2. Afghani B, Lieberman JM: Paradoxical enlargement or development of intracranial tuberculomas during therapy: case report and review. Clin Infect Dis 1994, 19: 1092-1099
3. Ben Hamid M, Chabbi N: Tuberculome optochiasmatic revele par une exophtalmie unilaterale. Etude clinico-pathologique. Rev Neurol (Paris) 1990, 146: 211-213
4. Bret PH, Huppert J, Fisher G, Hor F, Veraromeo F: Le tuberculome cerebral: A propos de deux observations. Lyon Medical 1984, 251: 95-98
5. Caparros-Lefevre D, Salomez JL, Petit H: Tuberculomes intracraniens multiples: Aspect en imagerie par resonance magnetique nucleaire et apport therapeutique de l’ofloxacine. Ann Med Interne 1989, 140: 679-701
6. Corcos A, Daum S, Lebeau J: Etat actuel de la chirurgie des tuberculomes cerebraux. Ann Med Interne 1972, 123: 865-870
7. Dooly DP, Carpentier JL, Rademacher S: Adjunctive corticosteriod therapy for tuberculosis: a critical reappraisal of the literature. Clin Infect Dis 1997, 25: 872-887
8. Dossou B, May T, Amiel C: Tuberculomes cerebraux: A propos de deux observations. Med Mal Infect 1992, 22: 481-486
9. Eide FF, Gean AD, So YT: Clinical and radiographic findings in disseminated tuberculosis of the brain. Neurol 1993, 43: 1427-1429
10. El Ouarzazi A, Chkili T, Hermo JF, Tournoux P: A ropos des tuberculoses encephaliques calcifies. Neuro-chriurgie 1973, 20: 147-159
11. Fath-Ordoubadi F, Lane RJM, Richards PG: Histological surprise: Callosal tuberculoma presenting as malignant glioma. J Neurol Neurosurg Psychiat 1997, 63: 98-99
12. Gavazzi G, Bouchard O, Bosseray A, Leclerq P, Micoud M: Miliaire tuberculeuse cerebrale et pulmonaire chez un patient immunocompetent: aggravation sous traitement adapte. Presse Medicale 1998, 27: 958-962
13. Gupta RK, Jena A, Singh AK, Sharma A, Puri V: Role of magnetic resonance in the diagnosis and management of intracranial tuberculomas. Clin Radiol 1990, 41: 120-127
14. Haas DW, Despres RM: Mycobacterium tuberculosis in: Principles and practices of infectious disease. Mandell GL, Benett JE, Dolin R. 4th (Ed). Churchill-Livingstone, New-York 1995: 1877-1906
15. Huchet B, Cayla J, Pradat P, Foncin JF: Tuberculome intramedullaire: A propos d’un cas, revue de la litterature. Sem Hop Paris 1984, 60: 2015-2018
16. Kchouk M, Ladeb MF, Benhamouda M, Ayadi M, Touibi S: Imagerie de la tuberculose du systeme nerveux central. Feuillet de Radiologie 1992, 32: 518-526
17. Kent SJ, Growe SM, Yun A, Lucas C, Mijch AM: Tuberculosis meningitis: a 30 years review. Clin Infect Dis 1993, 17: 987-994
18. Lecuit M, Rogeoux O, Bricaire F, Gentilin M: Tuberculomes intracerebraux au cours de l’infection par le VIH, epidemiologie et apport de l’imagerie par resonance magnetique. Presse Medicale 1994, 23: 891-895
19. Lejeune B, Mocquard Y, Estienne E: Tuberculomes intracerebraux: A propos de deux observations. Med Mal Infect 1987, 17: 38-40
20. Lisa M, Deangeli S: Intracranial tuberculoma: case report and review of the literature. Neurol 1981, 31: 1133-1136
21. Loizou LA, Milne A: Intracranial tuberculoma: Correlation of computerized tomography with clinicopathological findings. Quarterly J of Med 1982, new series L1: 104-114
22. Mitchell R, Gropper MR, Michael S, Harry L, Duran HL: Cerebral tuberculosis with expansion into brainstem tuberculoma. Report of two cases. J Neurosurg 1994, 81: 927-931
23. Miyajima M, Hatashita S, Ohnuki A, Takagi S: Tuberculoma of the cerebellum. Case report. Neurol Med Chir 1990, 30: 74-76
24. Mocquard Y, Chevalier F, Borsotti JP, Goas JS, Le Guyader J: Tuberculomes multiples intracerebraux. Diagnostic et controles tomodensitometriques de l’evolution. Ann Med Interne 1982, 136: 405-408
25. Tsukamura M, Nakamura E, Yoshii S: Therapy effect of a new antibacterial substance ofloxacine (DL8280) on pulmonary tuberculosis. Am Rev Respir Dis 1986, 131: 352-356
 


HOME | UP | FEEDBACK
Historical Notes | Executive Committee| Regional Societies and Links | Forthcoming Meetings
Bylaws | Journal | News and Letters

http://www.panarabneurosurgery.org/
Copyright 2001