Citation, DOI, disclosures and article data
At the time the article was created Bruno Di Muzio had no recorded disclosures.View Bruno Di Muzio's current disclosures
At the time the article was last revised Frank Gaillard had the following disclosures:
- Biogen Australia Pty Ltd, Investigator-Initiated Research Grant for CAD software in multiple sclerosis: finished Oct 2021 (past)
These were assessed during peer review and were determined to not be relevant to the changes that were made.View Frank Gaillard's current disclosures
Please refer to the article on rhombencephalitis for a general discussion of that entity.
Studies have shown that in the USA ~5% of all TB cases involve CNS, and this percentage rises to ~25% (range 15-40%) in patients with AIDS 2. Brainstem involvement is rare, corresponding only to ~5% (range 2.5-8%) of CNS tuberculomas 1.
Brainstem tuberculomas are usually focal lesions causing focal neurological symptoms related to the involvement of a cranial nerve nuclei. There may also be associated tuberculous meningitis and hydrocephalus.
CSF analysis typically shows 2:
increased leukocyte count
normal or low glucose levels
Mycobacterium tuberculosis, also known as Koch's bacillus.
Beam-hardening artifacts limit the visualization of the brainstem on CT images and MRI is the imaging modality of choice for the assessment of patients with suspected pathology in that anatomic location. Protocols, both on CT as on MRI, should include contrast.
As systemic tuberculosis is present in ~ 55% of brainstem tuberculomas 1, further investigation such as chest radiography should be considered.
Tuberculomas are usually presented as ring-enhancing lesions with a central hypointense area (necrotic center: solid caseous, fibrotic material, and macrophages).
isointense to grey-matter 3
may have central region of hyperintensity representing caseation
isointense to grey-matter
may have central region of hypointensity representing gliosis and abundant monocyte infiltration 3
lesions are surrounded by vasogenic edema
T1 C+ (Gd)
usually appears as ring-enhancement
may appear as a conglomerate enhancing mass
decrease in NAA/Cr
slight decrease in NAA/Cho
lipid-lactate peaks are usually elevated (86%) 4
Treatment and prognosis
Treatment of CNS tuberculosis is based on an anti-tubercular treatment regimen. However, multi-drug resistant tuberculosis remains a major hurdle in treatment.
- 1. Talamás O, Del Brutto OH, García-Ramos G. Brain-stem tuberculoma. An analysis of 11 patients. Arch. Neurol. 1989;46 (5): 529-35. Pubmed citation
- 2. Sahaiu-Srivastava S, Jones B. Brainstem tuberculoma in the immunocompetent: case report and literature review. Clin Neurol Neurosurg. 2008;110 (3): 302-4. doi:10.1016/j.clineuro.2007.11.002 - Pubmed citation
- 3. Kim TK, Chang KH, Kim CJ et-al. Intracranial tuberculoma: comparison of MR with pathologic findings. AJNR Am J Neuroradiol. 1995;16 (9): 1903-8. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 4. Khanna PC, Godinho S, Patkar DP et-al. MR spectroscopy-aided differentiation: "giant" extra-axial tuberculoma masquerading as meningioma. AJNR Am J Neuroradiol. 2006;27 (7): 1438-40. AJNR Am J Neuroradiol (full text) - Pubmed citation