Brain Tuberculomas

Abstract

Brain tuberculoma is a serious form of extrapulmonary tuberculosis. The incidence of the disease is increasing in developed nations largely because of immigration and epidemic HIV disease. Brain tuberculoma may be solitary or multiple, with or without tuberculous meningitis. Tuberculoma is often infratentorial in children and supratentorial in adults. It progresses slowly and insidiously, as a mass lesion. Dominant clinical manifestations include seizure, intracranial hypertension, and focal neurologic deficits. CT scan and MRI habitually demonstrate peripheral or uniform contrast-enhancing lesions with extensive perifocal edema. MRI spectroscopy and diffusion-weighted imaging may be helpful in making the diagnosis. Routine laboratory investigations are nonspecific. Etiological confirmation is frequently made either by demonstration of acid-fast bacilli in a pathology specimen or histological evidence of epithelioid–giant cell granulomas with caseous necrotic material. Stereotactic procedures have improved the safety of brain biopsy, and newer techniques are helpful for early and rapid diagnosis. Management of brain tuberculoma mainly involves long-term antituberculous drugs, but surgery may be required to obtain a definitive diagnosis, to relieve mass lesions or high intracranial pressure, or for CSF diversion. Most patients with a solitary tuberculoma sensitive to antituberculous therapy have a good outcome. Neurologic sequelae sometimes encountered include seizures, focal neurologic deficits, aphasia, blindness, and cognitive impairment. Drug-resistant infections are associated with a high mortality rate.