Cerebral tuberculosis with dural sinus invasion

Case contributed by Dr Ian Bickle

Presentation

Cystic mass midline of occiput. Thought to be a sebaceous cyst. Patient dizzy. No fever.

Patient Data

Age: 20 years
Gender: Female

6 cm mass in the central occipital area close to the vertex with a 1.8 cm bony defect.

The external component is cystic but the larger intracranial element is composed of solid enhancing soft tissue. This is irregular and extends along the posterior interhemispheric fissure and invades the sagittal sinus.

2.7 cm enhancing cystic lesion in the right occipital lobe.

Gross edema of the occipitoparietal regions bilaterally.

Comment: Large occipital skull/dural based mass

The differential includes haemangioperitocytoma, dural lymphoma, malignant meningioma and far less likely tuberculosis.

Immediate recall for contrast study

CT

See combined report above for CT head.

MRI BRAIN - with contrast and MRV

4 cm midline occipital cystic lesion which communicates through a smooth defect of 9 mm in the occipital bone. This directly communicates with thick irregular enhancing soft tissue surrounding and involving the posterior aspect of the sagittal sinus.

Several small sub-centimeter nodules along the course of the sagittal sinus. No flow in the mid and posterior aspects of the sagittal sinus.

2.4 cm rim enhancing cystic right occipital lobe lesion with avid internal restriction.

Intense, near symmetrical vasogenic edema in both parieto-occipital regions.

No hydrocephalus.

Infratentorial brain normal in appearance.

Comment:

1. Right occipital lobe cerebral abscess

2. Dural centered solid-cystic lesions - these appear most likely infectious-inflammatory in nature. Tuberculosis would be the first consideration.

3. Sagittal sinus occlusion with resultant cerebral edema.

Case Discussion

This one was a puzzler for a start.  Especially the manner in which it presented to the CT department.

The patient was apyretic and the presentation rather occult, making central nervous system (CNS) infection lower on the differential. Having said this, tuberculosis (TB) is renown for not necessarily presenting with pyrexia.

TB: the great mimicker.

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