What are Vascular Manifestations of Tuberculous Meningitis?
A recent study published by doctors of AIIMS Bhubaneshwar, highlights the vascular manifestations of tubercular meningitis (TBM), showing predominant arterial involvement causing infarcts which are usually seen in the tubercular zone, and occasional venous involvement causing cerebral venous sinus thrombosis.
The study is a cross section observational study, which was published in Journal of Neuroscienences in Rural Practice, was conducted by Naik et al. They enrolled thirty consecutive patients of clinically diagnosed TBM. Apart from T2-weighted imaging, T1-weighted imaging (T1WI), diffusion-weighted imaging, susceptibility-weighted imaging, fluid-attenuated inversion recovery, and postcontrast T1WI, time-of-flight (TOF) MRA and postcontrast MRV were done in all the patients. MRV was done after intravenous administration of gadolinium-based contrast agent followed by postcontrast T1WI. MRA and MRV findings were analyzed.
MRI findings were analyzed for the presence or absence of leptomeningeal enhancement, pachymeningeal enhancement, basal exudates, tuberculomas, abscess, ventriculitis, hydrocephalus, and vasculitic infarcts. The location of the cerebral infarcts was documented. The location and characteristics of tuberculoma were noted. MRA and MRV abnormalities were also analyzed by two radiologists with more than 11 years of experience.
They found Twenty-nine TBM (96.7%) patients had an abnormality on MRI. MR abnormalities were in varying combinations of leptomeningeal enhancement in 24 (80%), pachymeningeal enhancement in 2 (6.7%), both lepto- and pachymeningeal enhancement in 3 (10%), tuberculomas in 13 (43.3%), ventriculitis in 1 (3.3%), hydrocephalus in 16 (53.3%), and infarcts in 10 (33.3%). Cerebral infarcts were seen in 10 (33.3%) patients, out of which the tubercular zone is involved in 9 patients.
Arterial abnormality on TOF MRA was noted in 13 (43.3%) patients. The significant arterial narrowing was noted in four patients, whereas mild irregularity of vessels was noted in nine patients. Cerebral venous sinus thrombosis (CVST) was noted in two (6.7%) of patients. Both were female.
TBM is the most severe form of extrapulmonary TB. Cerebrovascular complications in TBM have been reported as a poor prognostic predictor. Vascular complications associated with TBM are usually secondary to arteritis causing arterial vasculitic infarcts.
The authors conclude that CVST in tubercular meningitis is rare and the clinical pictures may be overlapping. Early diagnosis and management are required for better outcome of the patient. Contrast-enhanced MRV with postcontrast T1WI is required for diagnosis of sinus thrombosis and meningitis. In TBM, there is predominant arterial involvement causing infarcts. However, occasionally, there may be venous involvement causing CVST.
Reference : Vascular Manifestations of Tuberculous Meningitis: MR Angiography and Venography Study
Suprava Naik , Sanjeev Kumar Bhoi , Nerbadyswari Deep , Sudipta Mohakud , Baijayantimala Mishra , Anupam Dey , Rajesh Kumar , Gautom Kumar Saharia  , Mukesh Kumar
J Neurosci Rural Pract 2022; 13(03): 529-536
DOI: 10.1055/s-0042-1748175
