Tuberculous meningitis

Case contributed by Heba Abdelmonem
Diagnosis almost certain


Long history of headache followed by a deteriorating conscious level

Patient Data

Age: 30 years
Gender: Female

- Diffuse abnormal high T2 and FLAIR signal of the brainstem, bilateral frontal, bilateral temporal, and left parietal subcortical white matter, associated with multiple rounded lesions with low T2 and FLAIR signal involving the bilateral cerebellar hemispheres, left cerebellopontine angle, and left parafalcine region, and most of the central part of the brain.

- Postcontrast series demonstrates diffuse enhancement of the basal meninges as well as multiple discrete/coalescing lesions, which display ring enhancement and have irregular walls of varying thickness representing caseating granulomas.

-VP shunt valve is seen in the right parietal regions and the 4th ventricle is dilated.

Case Discussion

Our presented case displays the most typical features of tuberculous meningitis including: leptomeningeal and basal enhancement, hydrocephalus with subsequent shunting, and the presence of tuberculomas

Headache, vomiting, meningeal irritation signs, neurological deficits, vision loss, cranial nerve palsies, and increased intracranial pressure are the most encountered clinical features of tuberculous meningitis. The sixth cranial nerve (VI) is the most frequently affected cranial nerve.

On MRI, two predominant types of tuberculomas are demonstrated:

  1. caseating tuberculomas are often hypointense on T1W images. On T2W images, the central portion of the granuloma is of a high signal with a peripheral hypointense rim. Ring enhancement is usually seen after contrast administration. A variable amount of perilesional edema represents with a hyperintense signal on T2W and FLAIR images. Tuberculomas are restricted on DWI and display low signal on ADC map.
  2. non-caseating (non-necrotizing) tuberculomas, are usually of low signal on T1W images and high signal on T2W images and often enhance homogeneously.

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