Pediatric Radiology

, Volume 36, Issue 7, pp 687–696 | Cite as

Objective CT criteria to determine the presence of abnormal basal enhancement in children with suspected tuberculous meningitis

  • Stefan Przybojewski
  • Savvas AndronikouEmail author
  • Jo Wilmshurst
Original Article



There are no widely accepted objective criteria to determine the presence of basal enhancement on CT in children with suspected tuberculous meningitis (TBM).


To test nine recently described objective CT criteria for the presence of abnormal basal enhancement in children with suspected TBM against the definite diagnosis as determined by cerebrospinal fluid (CSF) culture.

Materials and methods

CT scans of patients with a clinical suspicion of TBM who had undergone lumbar puncture for CSF culture spanning a period of 4 years were reviewed for the presence of nine recently described criteria for the presence of abnormal basal enhancement. The radiologists were blinded to the final diagnosis based on CSF culture against which the criteria were tested. The criteria have been named: the ‘Y-sign’, ‘linear enhancement’, ‘double lines’, ‘infundibular recess of the third’, ‘ill-defined edge’, ‘nodular enhancement’, ‘join the dots’, ‘contrast filling the cisterns’, and ‘asymmetry’.


A total of 65 patients were included in the study, 34 with culture-proven TBM and 31 with other diagnoses. Four individual criteria had a specificity of 100%, but the sensitivities of these criteria ranged from 15% to 53% only. Three other criteria had specificities of 97% and sensitivities ranging from 62% to 82%. The presence of more than one criterion in the same patient showed a specificity of 97% and sensitivity of 91%.


Very high specificity was demonstrated for all nine criteria, including 100% specificity for four individual criteria. Sensitivity was at best 82%, but improved to 91% when more than one criterion was present. These criteria need to be tested for inter- and intraobserver variability to prove their clinical usefulness.


Brain Meninges Tuberculosis CT Children 


  1. 1.
    Chang KH, Han MH, Roh JK, et al (1990) Gd-DTPA enhanced MR imaging in intracranial tuberculosis. Neuroradiology 32:19–25PubMedCrossRefGoogle Scholar
  2. 2.
    Cho IC, Chang KH, Kim YH, et al (1998) MRI features of choroid plexitis. Neuroradiology 40:303–307PubMedCrossRefGoogle Scholar
  3. 3.
    Bullock MR, Welchman JM (1982) Diagnostic and prognostic features of tuberculous meningitis on CT scanning. J Neurol Neurosurg Psychiatry 45:1098–1101PubMedCrossRefGoogle Scholar
  4. 4.
    Andronikou S, Smith B, Hatherhill M, et al (2004) Definitive neuroradiological diagnostic features of tuberculous meningitis in children. Pediatr Radiol 34:876–885PubMedCrossRefGoogle Scholar
  5. 5.
    Lan SH, Chang WN, Lu CH, et al (2001) Cerebral infarction in chronic meningitis: a comparison of tuberculous and cryptococcal meningitis. QJM 94:247–253PubMedCrossRefGoogle Scholar
  6. 6.
    Hooijboer PG, van der Vliet AM, Sinnige LG (1996) Tuberculous meningitis in native Dutch children: a report of four cases. Pediatr Radiol 26:542–546PubMedCrossRefGoogle Scholar
  7. 7.
    Leonard JM, Des Prez RM (1990) Tuberculous meningitis. Infect Dis Clin North Am 4:769–787PubMedGoogle Scholar
  8. 8.
    Worster A, Innes G, Abu-Laban RB (2002) Diagnostic testing: an emergency medicine perspective. Can J Emerg Med 4:348–354Google Scholar
  9. 9.
    Department of Health (1999) Epidemiological comments, vol 1, no. 2. Notifiable medical conditions 1999. Department of Health, Pretoria, Republic of South AfricaGoogle Scholar
  10. 10.
    Singhi PD, Singhi SC (1995) Central nervous system infections in children (bacterial, tubercular). Curr Opin Neurol 8:150–155PubMedCrossRefGoogle Scholar
  11. 11.
    Farinha NJ, Razali KA, Holzel H, et al (2000) Tuberculosis of the central nervous system in children: a 20 year survey. J Infect 41:61–68PubMedCrossRefGoogle Scholar
  12. 12.
    Katrak SM, Shembalkar PK, Bijwe SR, et al (2000) The clinical, radiological and pathological profile of tuberculous meningitis in patients with and without human immunodeficiency virus infection. J Neurol Sci 181:118–126PubMedCrossRefGoogle Scholar
  13. 13.
    Khan IM, Khan S, Laaser U (2003) Tuberculous meningitis: a disease of fatal outcome in children. Eur J Pediatr 162:281–282PubMedGoogle Scholar
  14. 14.
    Waecker NJ Jr, Connor JD (1990) Central nervous system tuberculosis in children: a review of 30 cases. Pediatr Infect Dis J 9:539–543PubMedCrossRefGoogle Scholar
  15. 15.
    Brown HM, Abbitt PL, Wilkinson EJ (2001) Diagnosis of clinically unsuspected extrapulmonary tuberculosis by fine needle aspiration. Acta Cytol 45:1032–1036PubMedGoogle Scholar
  16. 16.
    Ozates M, Kemaloglu S, Gurkan F, et al (2000) CT of the brain in tuberculous meningitis. A review of 289 patients. Acta Radiol 41:13–17PubMedCrossRefGoogle Scholar
  17. 17.
    Harisinghani MG, McLoud TC, Shepard JA, et al (2000) Tuberculosis from head to toe. Radiographics 20:449–470PubMedGoogle Scholar
  18. 18.
    Donald PR, Cotton MF, Hendricks MK, et al (1996) Pediatric meningitis in the Western Cape Province of South Africa. J Trop Pediatr 42:256–261PubMedCrossRefGoogle Scholar
  19. 19.
    Schutte CM (2001) Clinical, cerebrospinal fluid and pathological findings and outcomes in HIV-positive and HIV-negative patients with tuberculous meningitis. Infection 29:213–217PubMedCrossRefGoogle Scholar
  20. 20.
    Kumar R, Singh SN, Kohli N (1999) A diagnostic rule for tuberculous meningitis. Arch Dis Child 81:221–224PubMedCrossRefGoogle Scholar
  21. 21.
    Schoeman JF, Van Zyl LE, Laubscher JA, et al (1997) Effect of corticosteroids on intracranial pressure, CT findings and clinical outcome in young children with tuberculous meningitis. Pediatrics 99:226–231PubMedCrossRefGoogle Scholar
  22. 22.
    Bhargava S, Gupta AK, Tandon PN (1982) Tuberculous meningitis – a CT study. Br J Radiol 55:189–196PubMedCrossRefGoogle Scholar
  23. 23.
    De JK, Bagchi S, Bhadra UK, et al (2002) CT study of tuberculous meningitis in children. J Indian Med Assoc 100:603–604, 606. Erratum in: J Indian Med Assoc (2002) 100:678PubMedGoogle Scholar
  24. 24.
    Cassleman ES, Hasso AN, Ashwal S, et al (1980) Computed tomography of tuberculous meningitis in infants and children. J Comput Assist Tomogr 4:211–216PubMedCrossRefGoogle Scholar
  25. 25.
    Beskonakli E, Cayli S, Turgut M, et al (1998) Primary giant granulomatous basal meningitis: an unusual presentation of tuberculosis. Childs Nerv Syst 14:79–81PubMedCrossRefGoogle Scholar
  26. 26.
    Jinkins JR (1987) Dynamic CT of tuberculous meningeal reactions. Neuroradiology 29:343–347PubMedCrossRefGoogle Scholar
  27. 27.
    Ravenscroft A, Schoeman JF, Donald PR (2001) Tuberculous granulomas in childhood tuberculous meningitis: radiological features and course. J Trop Paediatr 47:5–12CrossRefGoogle Scholar
  28. 28.
    Kalita J, Misra UK (2001) Brainstem auditory evoked potentials in tuberculous meningitis and their correlation with radiological findings. Neurol India 49:51–54PubMedGoogle Scholar
  29. 29.
    Teoh R, Humphries MJ, Hoare RD, et al (1989) Clinical correlation of CT changes in 64 Chinese patients with tuberculous meningitis. J Neurol 236:48–51PubMedCrossRefGoogle Scholar
  30. 30.
    Kumar R, Kohli N, Thavnani H, et al (1996) Value of CT scan in the diagnosis of meningitis. Indian Pediatr 33:465–468PubMedGoogle Scholar
  31. 31.
    Andronikou S, Wieselthaler N (2004) Modern imaging of tuberculosis in children: thoracic, central nervous system and abdominal tuberculosis. Pediatr Radiol 34:861–875PubMedCrossRefGoogle Scholar
  32. 32.
    Moodley M, Bamber S (1990) The operculum syndrome: an unusual complication of tuberculous meningitis. Dev Med Child Neurol 32:919–922PubMedCrossRefGoogle Scholar
  33. 33.
    Naheedy MH, Azar-Kia B, Fine B (1983) Radiologic evaluation of tuberculous meningitis. Invest Radiol 18:224–229PubMedCrossRefGoogle Scholar
  34. 34.
    Misra UK, Kalita J, Srivastava M, et al (1996) Prognosis of tuberculous meningitis: a multivariate analysis. J Neurol Sci 137:57–61PubMedCrossRefGoogle Scholar
  35. 35.
    Witrak BJ, Ellis GT (1985) Intracranial tuberculosis: manifestations on CT. South Med J 78:386–392PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Stefan Przybojewski
    • 1
  • Savvas Andronikou
    • 1
    Email author
  • Jo Wilmshurst
    • 2
  1. 1.Department of RadiologyStellenbosch University Medical SchoolTygerbergSouth Africa
  2. 2.Department of Paediatric NeurologyRed Cross Children’s Hospital and School of Child and Adolescent HealthCape TownSouth Africa

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