Revision 11 for 'Intracranial tuberculous granuloma'

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Intracranial tuberculous granuloma

Intracranial tuberculous granulomas (also known as CNS tuberculomas) are common in endemic areas, and may occur either in isolation or along with with tuberculous meningitis.

Epidemiology

The epidemiology of patients with tuberculomas is the same as that of other CNS manifestations of TB (see CNS tuberculosis)

Pathology

A tuberculoma is distinct from a tuberculous abscess in that it demonstrates evidence of granulomatous reaction histologically, whereas abscesses do not 5. Not all tuberculomas have a solid granulomatous core and some may undergo liquefaction 4.  

Radiographic features

MRI

MRI is the modality of choice in assessing potential tuberculomas, and as long as liquefactive necrosis centrally has not occurred, the image appearances are fairly characteristic (see below). If liquefactive necrosis is present, then the imaging appearances are essentially indistinguishable from a tuberculous abscess, which in turn is similar to pyogenic cerebral abscesses 4

  • T1
    • isointense to grey-matter 1
    • may have central region of hyperintensity representing caseation
  • T2
    • isointense to grey-matter
    • may have central region of hypointensity representing gliosis and abundant monocyte infiltration 1
    • lesions are surrounded by vasogenic edema
  • T1 C+ (Gd)
    • usually appears as ring-enhancement
    • may appear as a conglomerate enhancing mass
  • DWI
    • typically central low signal (i.e. no restricted diffusion) 3 but if liquid necrosis is present centrally may be high signal
  • MR spectroscopy
    • decrease in NAA/Cr
    • slight decrease in NAA/Cho
    • lipid-lactate peaks are usually elevated (86%) 2

Differential diagnosis

The differential of tuberculomas is essentially is the differential of ring-enhancing lesions, and includes:

Central isointensity or hypointensity compared to grey matter seen centrally on T2 is helpful, as it is not seen in most other causes 1.

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