Abstract
Background: Although CT scanning is used widely for making the diagnosis and detecting the complications of tuberculous meningitis (TBM) in children, the radiological features are considered non-specific. CT is particularly suggestive of the diagnosis when there is a combination of basal enhancement, hydrocephalus and infarction, and even then the diagnosis may be in doubt. In this paper we introduce a new CT feature for making the diagnosis of TBM, namely, hyperdensity in the basal cisterns on non-contrast scans, and we assess which of the recognized CT features is most sensitive and specific. Objective: To determine the sensitivity and specificity of the presence of high-density exudates in the basal cisterns (on non-contrast CT) and basal enhancement (on contrast-enhanced CT) for the diagnosis of TBM in children, and to correlate these with the complications of infarction and hydrocephalus. Materials and methods: Retrospective review of CT scans with readers blinded to the diagnosis, which was based on a definitive culture of cerebrospinal fluid (CSF) for TBM or other bacteria. Computer-aided conversion of hard-copy film density to Hounsfield units was employed as well as a density threshold technique for determining abnormally high densities. Results: The most specific feature for TBM is hyperdensity in the basal cisterns prior to IV contrast medium administration (100%). The most sensitive feature of TBM is basal enhancement (89%). A combination of features (hydrocephalus, infarction and basal enhancement) is as specific as pre-contrast hyperdensity, but has a lower sensitivity (41%). There were statistically significant differences in the presence of hydrocephalus (p=0.0016), infarcts (P=0.0014), basal enhancement (P<0.0001) and pre-contrast density (P<0.0001) between the negative and positive TBM patient groups. The presence of granulomas was not statistically significant between the two groups (P=0.44). Conclusions: The presence of high density within the basal cisterns on non-contrast CT scans is a very specific sign for TBM in children. This will enhance diagnostic confidence, allow early institution of therapy and could reduce expenditure on contrast medium, scan time and radiation exposure. With the use of threshold techniques we believe that the pre-contrast hyperdensity may be detectable by a computer program that will facilitate diagnosis, and may also be modified to detect abnormal enhancement. Basal enhancement is a sensitive sign for the diagnosis of TBM and should be sought after contrast medium administration when no hyperdensity is seen in the basal cisterns or when this finding needs to be confirmed. The CT scan feature of hyperdense exudates on pre-contrast scans should be added to the inclusion criteria for the diagnosis of TBM in children.
Similar content being viewed by others
References
Waeker NJ, Connor JD (1990) Central nervous system tuberculosis in children: a review of 30 cases. Pediatr Infect Dis J 9:539–543
Katrak SM, Shenbalkar PK, Bijwe SR, et al (2000) The clinical, radiological and pathological profile of tuberculous meningitis in patients with and without HIV infection. J Neurol Sci 181:118–126
Kumar R, Singh SN, Kohli N (1999) A diagnostic rule for tuberculous meningitis. Arch Dis Child 81:221–224
Farinha NJ, Razali KA, Holzel H, et al (2000) Tuberculosis of the central nervous system in children: a 20-year survey. J Infect 41:61–68
Tung Y-R, Lai M-C, Lui C-C, et al (2002) Tuberculous meningitis in infancy. Pediatr Neurol 27:262–266
Lamprecht D, Schoeman J, Donald P, et al (2001) Ventriculoperitoneal shunting in childhood tuberculous meningitis. Br J Neurosurg 15:119–125
Ahuja GK, Mohan KK, Prasad K, et al (1994) Diagnostic criteria for tuberculous meningitis and their validation. Tuber Lung Dis 75:149–152
Altunbasak S, Alhan E, Baytok V, et al (1994) Tuberculous meningitis in children. Acta Paediatr Jpn 36:480–484
Kumar R, Kohli N, Thavnani H, et al (1996) Value of CT scans in diagnosis of meningitis. Indian Pediatr 33:465–468
Scheoman JF, Van Zyl LE, Laubscher JA, et al (1995) Serial CT scanning in childhood tuberculous meningitis: prognostic features in 198 cases. J Child Neurol 10:320–329
Bullock MR, Welchman JM (1982) Diagnostic and prognostic features of tuberculous meningitis on CT scanning. J Neurol Neurosurg Psychiatry 45:1098–1101
Casselman ES, Hasso AN, Ashwal S, et al (1980) Computed tomography of tuberculous meningitis in infants and children. J Comput Assist Tomogr 4:211–216
Teo R, Humphries MJ, Hoare RD, et al (1989) Clinical correlation of CT changes in 64 Chinese patients with tuberculous meningitis. J Neurol 236:48–51
Witrak BJ, Ellis GT (1985) Intracranial tuberculosis: manifestations on computerised tomography. South Med J 78:386–392
Kingsley DP, Hnedrickse WA, Kendall BE, et al (1987) Tuberculous meningitis: role of CT in management and prognosis. J Neurol Neurosurg Psychiatry 50:30–36
Hosoglu S, Geyik ME, Balik I,et al (2002) Predictors of outcome in patients with tuberculous meningitis. Int J Tuber Lung Dis 6:64–70
Leonard JM, Des Prez RM (1990) Tuberculous meningitis. Infect Dis Clin North Am 4:769–787
Rovira M, Romero F, Torrent O, et al (1980) Study of tuberculous meningitis by CT. Neuroradiology 19:137–141
Traut A, Trautmann M, Kluge W, et al (1986) Computed tomography in CNS tuberculosis. Eur Neurol 25:91–97
Gelabert M, Castro-Gago M (1988) Hydrocephalus and tuberculous meningitis in children: report on 26 cases. Childs Nerv Syst 4:268–270
Schoeman JF, Hewlett R, Donald P (1988) MR of childhood tuberculous meningitis. Neuroradiology 30:473–477
Ozates M, Kemaloglu S, Gurkan F, et al (2000) CT of the brain in tuberculous meningitis. Acta Radiol 41:13–17
Daoud A, Omari H, Al-Sheyyab M, et al (1998) Indications and benefits of CT in childhood bacterial meningitis. J Trop Pediatr 44:167–169
Patwari AK, Aneja S, Ravi RN, et al (1996) Convulsions in tuberculous meningitis. J Trop Pediatr 42:91–97
De JK, Bagchi S, Bhadra UK, et al (2002) Computerised tomographic study of tuberculous meningitis in children. J Indian Med Assoc 100:603–604, 606
Hooijboer PG, Van der Vliet AM, Sinnige LG (1996) Tuberculous meningitis in native Dutch children: a report of 4 cases. Pediatr Radiol 26:542–546
Moodley M, Bamber S (1990) The operculum syndrome: an unusual complication of tuberculous meningitis. Dev Med Child Neurol 32:919–922
Hosoglu S, Ayaz C, Geyik MF, et al (1998) Tuberculous meningitis in adults: an eleven year review. Int J Tuber Lung Dis 2:553–557
Schoeman JF, Van Zyl LE, Laubscher JA, et al (1997) Effect of corticosteroids on intracranial pressure: computed tomographic findings and clinical outcome in young children with tuberculous meningitis. Pediatrics 99:226–231
Buttaro TM, Ezell B, Gray V (1995) A care plan for children with tuberculosis. Public Health Nurs 12:181–188
Schutte CM (2001) Clinical, cerebrospinal fluid and pathological findings and outcomes in HIV-positive and HIV-negative patients with tuberculous meningitis. Infection 29:213–217
Lan S-H, Chang WN, Lu C-H, et al (2001) Cerebral infarction in chronic meningitis: a comparison of tuberculous meningitis and cryptococcal meningitis. QJM 94:247–253
Clark WC, Metcalf JC, Muhlbauer MS, et al (1986) Mycobacterium tuberculosis meningitis: a report of twelve cases and a literature review. Neurosurgery 18:604–610
Bhargava S, Gupta AK, Tandon PN (1982) Tuberculous meningitis—a CT study. Br J Radiol 55:189–196
Campi de Castro C, Garcia de Barros N, de Souza Campos ZM, et al (1995) CT scans of cranial tuberculosis. Radiol Clin North Am 33:753–769
Anonymous (1992) Neuroradiology case of the day. Meningitis caused by Neisseria meningitidis. AJR 158:1380–1381
Jinkins JR (1987) Dynamic CT of tuberculous meningeal reactions. Neuroradiology 29:343–347
Gado MH, Phelps ME, Coleman RE (1975) An extravascular component of contrast enhancement in cranial computed tomography. 1. The tissue-blood ratio of contrast enhancement. Radiology 117:589–593
Schoeman JF, Laubscher JA, Donald PR (2000) Serial lumbar CSF pressure measurement and cranial computed tomographic findings in childhood meningitis. Childs Nerv Syst 16:203–208; discussion 209
Kemaloglu S, Ozkan U, Bukte Y, et al (2002) Timing of shunt surgery in childhood tuberculous meningitis with hydrocephalus. Pediatr Neurosurg 37:194–198
Schoeman JF, Le Roux D, Bezuidenhoudt PB, et al (1985) Intracranial pressure monitoring in tuberculous meningitis: clinical and CT correlation. Dev Med Child Neurol 27:644–654
Chang K-H, Han M-H, Roh J-K, et al (1990) Gd-DTPA enhanced MR imaging in intracranial tuberculosis. Neuroradiology 32:19–25
Artopoulos J, Chalemis Z, Christopoulos S, et al (1984) Sequential computed tomography in tuberculous meningitis in infants and children. Comput Radiol 8:271–277
Leiguarda R, Berthier M, Starkstein S, et al (1988) Ischaemic infarction in 25 children with tuberculous meningitis. Stroke 19:200–204
Ravenscroft A, Schoeman JF, Donald PR (2001) Tuberculous granulomas in childhood tuberculous meningitis: radiological features and course. J Trop Pediatr 47:5–12
Kalita J, Misra UK (2001) Brainstem auditory evoked potentials in tuberculous meningitis and their correlation with radiological findings. Neurol India 49:51–54
Misra UK, Kalita J, Srivastava M, et al (1996) Prognosis of tuberculous meningitis: multivariate analysis. J Neurol Sci 137:57–61
Upadhyaya P, Bhargava S, Sundaram KR, et al (1983) Hydrocephalus caused by tuberculous meningitis: clinical picture, CT findings and results of shunt surgery. Z Kinderchir 38[Suppl 2]:76–79
Acknowledgements
We are grateful to Dawn Skippers, Jessica Bertelsmann, Barbara Duminiet and Catherine Clement for their help with film collection and filing over many months. We also thank Warren Halberstadt for his innovation and dedication to biomedical engineering.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Andronikou, S., Smith, B., Hatherhill, M. et al. Definitive neuroradiological diagnostic features of tuberculous meningitis in children. Pediatr Radiol 34, 876–885 (2004). https://doi.org/10.1007/s00247-004-1237-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00247-004-1237-1