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surgery
Moderators
Dr Ashish Suri
Dr Dee ak Gu ta
Dr Ajay Bisht
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TuberculosisAs old as recorded history
Symptoms described in the Rig Veda (1500 BC)
Unequivocal lesions in Egyptian mummies
Odier, Ford described meningeal TB 1790
urg ca exc s on ern c e an a n 1882,3/11/2010 CNS tuberculosis imaging and surgery 2
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Tuberculosis CNS tuberculosis complicates 10% of all TB
ever t e rst man estat on
ccurs w n 12 mon s
rc e o s more requen y nvo ve an ebasilar system
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Mycobacterium tuberculosisAcid fast bacillus
Does not stain on gramsta n
Obligate aerobes cu o grow
High lipid in cell wall
om n s ov ne v um
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Pathogenesis May develop during initial infection/ reactivation
Haematogenous dissemination
Commonest
Rupture of focus into subarachnoid/ ventricular space
Contiguous spread
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CNS tuberculosis Intracranial
Parenchymal
en ngea
Osseous
S inal Parenchymal
Meningeal
Arac noi itis
Osseous
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Epidemiology Incidence varies blacks > whites
Predominantly in theyoung (50%
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Pathology Immature lesions multiple tubercles in oedematous
brain
Mature: avascular mass, nodular extensions, yellowish
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Pathology (parrenchymal) Can be present anywhere
Cerebellum in children
Cerebral hemisphere and basal ganglia commoner inadults
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Pathology (tuberculoma) Tuberculoma ( classical lesion)
Tuberculoma en plaque
Tuberculous abscess
Cystic tuberculoma Multiple grape like tuberculoma
Microtuberculoma
Calcified tuberculoma
Tuberculous encephalopathy
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Pathology (tuberculoma) Dastur described six main types
Parenchymal changes.
(1) Ventriculitis
(2) Borderzone encephalitis
3 n arct on
(4) Internal hydrocephalus
(5) Diffuse oedema
6 Tu ercu oma
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Pathology (meningeal) Classically Commonest in 6m 3 years
Now adults 50%
Thick exudate encasing nerves, vessels
HCP, tuberculoma, arachnoiditis Diffuse perivasculitis
Infarcts
Pachymeningitis
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Diagnosis Montoux test
Hb/ ESR
CXR
ELISA CSF
PCR
Imaging
Biopsy
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ImagingX ray
Angiography of historical significance
CT
MRI
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Imaging Tuberculoma
Typically cortical and subcortical
u p e n 1035
Milliary rare ( children)
Menin itis commonest form of CNS TB Isolated meningitis is rare (5% in children)
Basal cisterns
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Imaging (CT tuberculoma) Cerebritis: hypodense areas
Perilesional oedema out of proportion ,
enhancement
Evolved : well delineated ring enhancing mass, target signcentra en ancement or ca c cat on
Healed: often calcify
Manifestations Small disc/ rings
Large rings with central lucency
Lar e nodular mass with irre ular outline
Multiple lesions in 1520%
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Caseating tuberculosis granulomainvolving the left temporal lobe.CECT shows a rim-enhancinglesion in the left temporal lobe
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consistent with a caseatingtuberculosis granuloma
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Imaging (MRI tuberculoma) T1 : isointence
T2: central hyper with hypo ring
Marked thin rim enhancement
Hypo on T2: fibrosis, gliosis, macrophage infiltration
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Parrenchymal tuberculosis. contrast-enhanced T1-
weighted MR image demonstrates multiple
enhancing caseating and non-caseating
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,
and parietal lobes
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Milliary CNS tuberculosis. Axial contrast-enhanced T1-
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weighted MR image shows multiple small high-signal-intensity foci within both cerebral hemispheres
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(a) Sagittal T2- hyperintensity in the cervical spinal cord extending from C2 to C7. Ahypointense nodule representing the granuloma is noted at the C4 level.(b) Sagittal T1 & (c) axial T1- with fat suppression after contrast reveal an area of
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-
the spinal cord. A smaller enhancing granuloma is also noted at the C2 level on thesagittal image
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MRS
decrease in NAA/Cr
slight decrease in NAA/Cho
-
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A. Bernaerts, F. M. VanhoenackerTuberculosis of the central nervous system: overview of
neuroradiological findings. Eur Radiol (2003) 13:18761890
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Imaging (meningitis)Active
Sequelae
Hydrocephalus
Ischemia and infarction e a en cu os r a e 75
Thalamoperforating
Cortex 25%
Bilateral 70%
Atrophy
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Imaging (CT meningitis) NCCT:
scans may be normal Obliteration of basal cisterns by hypo/ iso dense exudate
en p aque ura t c en ng Popcorn calcification
Hydrocephalus
Infarcts
CECT: Abnormal meningeal enhancement (may persist) Leptomeningeal enhancement sylvian fissures, tentorium Granulomas in the basal meninges
Ependymitis
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Imaging (MRI meningitis) Unenhanced scan: does not show active meningitis
Spine
CSF ocu ations
Obliteration of arachnoid space
Loss of cord outline in cervicodorsal cord
Thickening and clumping of roots in the lumbar cord
Contrast T1 : basal meningeal enhancement
spine
Linear enhancement of cord/ roots
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Tuberculous meningitis. Axial contrast-enhanced
T1-weighted magnetic resonance (MR) image
shows florid meningeal enhancement that is mostpronounced within the basal cisterns
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Tubercular meningitis. Axial FLAIR-MR]s ow ng mar e yper n ens y o e asacisterns and prominent temporal horns in apatient with mild communicatinghydrocephalus
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Caseating dural /epidural tuberculosis granuloma orabscess
-
b) Axial T1 contrast- dural/epidural rim enhancement suggestive of caseating tuberculosisgranuloma or abscess.
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c ag tta en ance - t e caseat ng ura ep ura tu ercu os s granu oma or a scess
posterior to the clivus. Abnormal meningeal enhancement is present
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Spinal tuberculous meningitis. Sagittal gadolinium-
enhanced T1-weighted MR image of the thoracic spine
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demonstrates irregular, linear, nodular meningealenhancement
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Enhanced T1-weighted magnetic resonance imaging with fat suppression show intense
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Tu ercu ous pac ymeningitis Rare
Common sites of involvement are cavernous sinus, floor of
middle cranial fossa and tentorium.
CT
hyperattenuating solid plaque like densitiesca ci ication may e seen
MRI
T1 : h o intense thickened duramater. T2 : hypo intense thickened meninges.
T1 C+ (GAD) : intense homogenous enhancement of thickenedmeninges.
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Management Medical therapy
Surgery
indications s on or e t reatene y mass e ect
Failure of response to medical therapy
Paradoxical increase in lesion size with therapy Diagnosis in doubt
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WHO recommendations
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WHO Treatment of tuberculosis: guidelines 4th ed.
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ura on o rea men6 months
van Loenhout-Rooyackers JH, Keyser A, Laheij RJ, Verbeek AL, van der Meer JW.
Tuberculous meningitis: Is a 6-month treatment regimen sufficient? Int J Tuberc Lung Dis2001;5:128-35.
12 months
, . , .
Neurol 2005;4:160-70
18 months or Longer
Santosh Isac Poonnoose Vedantam Rajashekhar: Rate of Resolution of histologically
verified intracranial tuderculomas. Neurosurgery 53:873-879 2003
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Treatment
Rate of radiological resolution of intracranial tuberculoma
Series duration of ATT residual lesions %
Wang 1996 (16) 6 20
Awada 1998 (2) 12 0Poonnoose 2003 (28) 18 69.2
Santosh Isac Poonnoose, Vedantam Rajashekhar: Rate of Resolution ofhistologically verified intracranial tuderculomas. Neurosurgery 53:873-879,
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Medical management 4 rugs x 34 mont s
2 drugs x 1416 months occasionally longer
Most resolve in 1214 monthsR Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of thenervous s stem. Schmidek and Sweet o erative neurosur ical techni ues th edition16171631
AED to continue
Steroids in all irrespective of age and stage
Prasad K, Singh MB. Corticosteroids for managing tuberculous meningitis.
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Cochrane Database Syst Rev 2008;1:CD002244.
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Resistant tuberculosis MDR : resistant to INH and Rifampicin
EDR/ XDR : MDR + resistance to Quinolones andinjecta e secon ine rugs
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Surgery Severe elevation of ICP
Threatening life or vision
Do not respond to drugs clinically/ radiologically
Diagnosis in doubt
Obstructive hydrocephalusR Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of the nervoussystem. Schmidek and Sweet operative neurosurgical techniques 5th edition; 16171631
m agnos s re eve pressure
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Surgical management Biopsy of the mass lesion
Hydrocephalus Communicating (commoner)
Non communicating
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Surgery principles Non eloquent areas total excision (small lesion)
Subtotal/ partial excision (large lesion/ eloquentcortex
Conservative excision around vital structures vacuat on o centra qu act ve port on n eep
seated lesions
R Patir, R Bhatia, Tandon PN. Surgical management of tuberculous infections of the
nervous system. Schmidek and Sweet operative neurosurgical techniques 5th edition; 16171631
y rocep a us3/11/2010 CNS tuberculosis imaging and surgery 47
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MRC Grading for hydrocephalus
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Vellore grading Modified Vellore grading
Mathew JM, Rajshekhar V, Chandy MJ. Shunt surgery for poor grade patients with tuberculous meningitis
and hydrocephalus: Effect of response to external ventricular drainage and other factors on long-term
, , , , .tubercular meningitis: A long-term follow-up study. J Neurosurg 1991;74:64-9
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outcome. J Neurol Neurosurg Psychiatry 1998;65:115-8
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Rajshekhar V. Management of hydrocephalus in patients
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with tuberculous meningitis. Neurol India 2009;57:368-74
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Hydrocephalus Inevitable in those who survive 46 weeks
Mortality 20100%
Grade at admission significant
Early shunt for grade I,II
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ETV 73.1% success rate for ETV in TBM with hydrocephalus
A chugh, M hussain et al. Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic thirdventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy: J
Neurosurg Pediatrics 3:000000, 2009
Endovascular revascularization for ischemia
STA MCA bypass
be capable of preventing new ischemic events in the 21monthfollowup period Martin misch, Ultrich wilhelm et al. Prevention of secondary ischemic events by superficial temporal
arterymiddle cerebral artery bypass surgery after tuberculosisinduced vasculopathy in a 5yearold
child:Neurosurg Pediatrics 6:000000, 2010
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SUPRATENTORIAL 78
PARIETAL 28
FRONTAL 26TEMPORAL 1
BG / THALAMUS 4
SELAR/SUPRASELLAR 4
INFRATENTORIAL 50
CEREBELLUM 44
CP ANGLE 3
TENTORIUM 1
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Thank you