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Abstract
Tuberculosis (TB) remains a major global problem and a public health issue of considerable magnitude. TB in any form is a
devastating disease, which in its most severe form involves the central nervous system (CNS), with a high mortality and morbidity.
There is a wide spectrum of CNS involvement in TB. Early diagnosis of CNS TB is crucial in appropriate management and in reducing
morbidity and mortality. Noninvasive imaging modalities such as computed tomography (CT) scan and magnetic resonance
imaging (MRI) are routinely used in the diagnosis of neurotuberculosis with MRI offering greater inherent sensitivity and specificity
than CT scan. In addition to conventional MRI imaging, magnetisation transfer, diffusion and magnetic resonance spectroscopy
techniques are also being evaluated for better tissue characterisation in CNS TB. The current pictorial essay describes the MRI
spectrum of CNS TB.
* Associate Professor, ** Junior Resident, *** Lecturer, Department of Radiodiagnosis, **** Associate Professor,
***** Professor, Department of Medicine, Sarojini Naidu Medical College, Agra - 282 002, Uttar Pradesh.
widening of subarachnoid spaces with associated T1 and
T2 shortening of CSF. Post-contrast T1 images show diffuse
meningeal enhancement around basal cisterns and
sylvian fissures (Fig.1). This appearance is nonspecific and
has a wide differential diagnosis that includes meningitis
from other infective agents, inflammatory diseases such
as rheumatoid arthritis, and sarcoidosis and neoplastic
causes.
84 Journal, Indian Academy of Clinical Medicine z Vol. 14, No. 1 z January-March, 2013
Fig. 4 : Miliary tuberculosis: Axial post-contrast image shows multiple < 2
mm well-defined solid enhancing lesions.
Journal, Indian Academy of Clinical Medicine z Vol. 14, No. 1 z January-March, 2013 85
involvement. They may also occur in patients with TB
meningitis. It is characterised by diffuse infiltration of brain
by multiple small granulomas (< 2 mm) which have high
or low signal on T2-weighted images (Fig. 4). Post-contrast
shows numerous round areas of intense enhancement.
Leptomeningeal granulomas show similar appearance;
however, they are seen located in the sulcal spaces and
basal cisterns (Fig. 5).
Tuberculous abscess
Tuberculous abscesses are occasionally seen. They occur
in less than 10% of patients with CNS TB and are more
common in the elderly and immunocompromised. They
may be solitary or multiple and are frequently
multiloculated. On imaging, a TB abscess may be
indistinguishable from a caseating tuberculoma or a
pyogenic abscess. However, TB abscess has thinner and
smoother enhancing walls, is larger (> 3 cm in diameter),
and it has peripheral oedema and mass effect (Fig. 6a, b).
Differentiation of TB abscess from pyogenic abscess can
be done with MR spectroscopy and magnetisation
transfer (MT) imaging8. On MR spectroscopy, TB abscess
does not demonstrate aminoacids at 0.9 ppm as
compared to pyogenic abscess which shows amino acids
at 0.9 ppm. MT ratio in a TB abscess is lower than that found
in a pyogenic abscess.
Tuberculous encephalopathy
Tuberculous encephalopathy, a syndrome exclusively
present in infants and children, has been described by
Udani and Dastur9 in Indian children with pulmonary
tuberculosis. The characteristic features of this entity are
the development of a diffuse cerebral disorder in the form
of convulsions, stupor, and coma, without signs of
meningeal irritation or focal neurological deficit.
Pathologically, there is diffuse oedema of cerebral white
matter with loss of neurons in the grey matter.
Neuroimaging shows severe unilateral or bilateral cerebral
oedema. On T2-weighted images, hyper-intensity is seen
in white matter suggesting myelin loss.These patients also Fig. 6 a, b: Tuberculous cerebellar abscess: Axial T2W (a) and post-
show diffuse alteration of MT ratio in white matter which contrast T1W (b) shows ring-enhancing well-defined regular thin-walled
reverts back to normal after clinical recovery. abscess.
86 Journal, Indian Academy of Clinical Medicine z Vol. 14, No. 1 z January-March, 2013
Cranial neuropathies
Cranial neuropathies are seen commonly in association
with TB meningitis. These are partly due to vascular
Fig. 7 a, b: Tuberculous cerebritis: Axial T2W FLAIR image (a) shows well-
defined round hypo-intense tuberculous nodule with caseation and post-
contrast T1W image (b) shows patchy enhancement.
Journal, Indian Academy of Clinical Medicine z Vol. 14, No. 1 z January-March, 2013 87
compromise resulting in ischaemia of nerve or may be meningitis is similar to that of TBM: a submeningeal tubercle
due to entrapment of nerves by the exudates. Large forms during primary infection and ruptures into the
tuberculomas may also compress the nerves, resulting in subarachnoid space eliciting mediators of delayed
compression neuropathy. Commonly affected are II, III, IV, hypersensitivity. As with intracranial lesions, there is
and VII cranial nerves. On MR imaging, the affected nerves granulomatous inflammation with areas of caseation and
appear thickened and may show hyper-intensity on T2- tubercles with eventual development of fibrous tissue in
weighted images. On contrast, the proximal portion of the chronic or treated cases. The clinical features are
nerve root is commonly affected and may show indistinguishable from those of any extramedullary or
enhancement (Fig. 9a, b). intramedullary tumour,although acute worsening may occur.
Non-osseous spinal cord tuberculosis MRI features include CSF loculation, and obliteration of
the spinal subarachnoid space with a loss of outline of
Non-osseous spinal cord tuberculosis can occur in the form the spinal cord in the cervico-thoracic spine, and matting
of tuberculomas. Extramedullary lesions are more common; of the nerve roots in the lumbar region. Sometimes,
of them, the majority being extradural. Intramedullary patients who appear normal on unenhanced MRI images
tuberculomas are very rare. Cervico-thoracic cord is may show nodular, thick, linear, intradural enhancement,
commonly involved. The pathophysiology of spinal often completely filling the subarachnoid space on post-
contrast images10, 11. Spinal cord involvement in the form
of infarction and syringomyelia may occur as a
complication of arachnoiditis. Parenchymal TB myelitis and
tuberculoma formation may also occur (Fig. 10a, b, c).
Fig. 9 a, b, c: Tuberculoma causing compression neuropathy of optic nerve: In a patient with visual symptoms, post-contrast T1W image (a) revealed enhancing
lesions in the suprasellar cistern compressing the optic chiasma. Sagittal plain T1W image (b) and post-contrast T1W image (c) shows contrast enhancement.
The visual symptoms were due to optic chiasma compressed by the TB granuloma.
88 Journal, Indian Academy of Clinical Medicine z Vol. 14, No. 1 z January-March, 2013
literature were in patients younger than 10 years, and 70 - Tuberculosis may present as a subgaleal swelling (Pott’s
90% were younger than 20 years. The disease is rarely seen puffy tumour) with a discharging sinus when the outer
in infants. It is believed that calvarial tuberculosis occurs table is involved (Fig.12a, b). Involvement of the inner table
by haematogenous seeding of bacilli into the diploic is associated with formation of underlying extradural
space. Lymphatic dissemination of tuberculosis, common granulation tissue.
in other bones, is not thought to occur in the skull12,13.
Fig.10 a, b, c: Intramedullary granulomas: Post-contrast T1W images (a, b & c) show multiple intramedullary ring-enhancing lesions in the upper cervical cord
with adjacent dural enhancement.
Fig. 11 a, b: Epidural abscess with osteomyelitis: Axial T2W image (a) shows a well-defined epidural hyperintense focus with thinning of adjacent inner table of
skull and extracranial soft-tissue swelling. Post-contrast T1W image (b) shows ring enhancement and dural tail.
Journal, Indian Academy of Clinical Medicine z Vol. 14, No. 1 z January-March, 2013 89
MR imaging, in most cases, leads to a conclusive diagnosis. sensitive in demonstrating changes in the meninges and
Proton density and T2-weighted images show a high- the ventricular walls and in detecting parenchymal foci
signal-intensity soft-tissue mass within the defect in bone. of involvement.
This may project into the subgaleal and/or epidural spaces
Dural and subdural pathology: Tuberculous pus
and show peripheral capsular enhancement on the
formation occurs between the dura and the
contrast-enhanced image (Fig.11a,b). MR imaging is
leptomeninges and may appear loculated. It appears
hyper-intense on T2W and iso- to hypo-intense on T1W
images. The dural granulomas appear hypo- to isointense
on T2W, and iso-intense on T1W images. Rim enhancement
can be seen on post-contrast images.
Epidural TB: Lesions generally appear to be iso-intense on
T1W images, and have mixed intensity on T2W images. In
post-contrast images, uniform enhancement can be seen
if the TB inflammatory process is phlegmonous in nature
whereas peripheral enhancement is seen if true epidural
abscess formation or caseation has developed 11. Epidural
tuberculous abscess may occur as primary lesions or may
be seen in association with an underlying tuberculous
focus.
Conclusion
CNS TB is a major cause of morbidity and mortality in
patients with tuberculosis. MR imaging plays a crucial role
in diagnosis because of its inherent sensitivity and
specificity in detecting CNS lesions earlier than CT. We
conclude that conventional imaging supplemented by
advanced MRI techniques helps in improved detection
and characterisation of CNS tuberculosis and may help in
better management of these patients.
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