Tuberculosis: The invading disease of the central nervous

system.

Poster No.: C-1497

Congress: ECR 2019
Type: Educational Exhibit
Authors: 1 2 3
M. A. Cruz Marmolejo , J. D. J. IUIT , A. E. Maciel Fierro , B.
1 1 3
Zavala , P. Lopez , A. HERNANDEZ TREJO , Z. M. Flores
3 1 2 3
Reyna ; Ciudad de México/MX, CDMX/MX, Mexico/MX
Keywords: Infection, Abscess, Diagnostic procedure, MR, CT, Neuroradiology
spine, Neuroradiology brain, CNS
DOI: 10.26044/ecr2019/C-1497

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Page 1 of 25
Learning objectives

1. Review the epidemiology and pathogenesis of dissemination of tuberculosis

in the central nervous system.
2. The radiologist and radiology residents must be familiarized with clinical
features, diagnosis, and the multiple imaging modality findings in
tuberculosis of the central nervous system.
3. Examine most common and specific imaging findings in computed
tomography and magnetic resonance of parenchymal, non parenchymal
central nervous system and spinal tuberculous involvement.

Page 2 of 25
Background

Tuberculosis (TB) continues to be a leading cause of morbidity and mortality as

appearance of drug resistant TB strains and the rise of immunodeficiency states make it a
diagnostic challenge in all hospital environments. In 2016 the World Health Organization
estimated there were 10.4 million people infected with TB of these 10% were HIV positive
[1], in this population central nervous system (CNS) involvement occurred in up to 15%
of patients [2]. Other sources of immunodeficiency must be sought carefully in the setting
of probable CNS TB such as diabetes, steroid use, and biological or chemotherapy. CNS
tuberculosis accounts for 1.3% of all TB infections and in endemic countries such as those
in Latin America a tuberculoma can represent 5-30% of all intracranial masses [3,4].

Mycobacterium Tuberculosis is responsible for almost all cases of central nervous

system involvement [3]. Hematogenous spread from lungs is the most common, as to
CNS involvement a "two step" model has been proposed: during primary tuberculosis
bacillemia the bacteria reaches oxygen rich areas in the CNS establishing a center called
"Rich focus" usually located in the meninges, subpial, subependymal regions of the brain
or in the spinal cord. These foci can remain dormant for years and in a matter of time
can grow or rupture into the subarachnoid space and depending on the bacteremia and
immune system capabilities of the host can produce one of the many types of CNS
involvement [5,6]. Spinal involvement occurs though hematogenous spread from the
Baston plexus.

The spectrum of central nervous system tuberculosis is wide but can be classified into two
main groups non parenchymal or meningeal, which constitutes 70-80% of all cases, and
parenchymal forms. The hallmark of parenchymal involvement is parenchymal infection
with central caseating necrosis known as TB granuloma or tuberculoma. Tuberculous
spondylodiscitis and spinal meningitis are the most common forms of spinal TB.

Clinical manifestations of tuberculous meningitis are characterized by persistent low

grade fever and headache with eventual neck stiffness, photophobia, nausea, vomiting
and confusion. Cranial nerve associations are also common mainly involving CNs III,
IV and VI. Tuberculomas manifest as an intracranial mass with clinical manifestations
usually depending on the region involved mainly as seizures and symptoms of increased
intracranial pressure [3,7,8,9].

Page 3 of 25
Diagnosis is made based on clinical features, abnormal cerebrospinal fluid (CSF),
imaging and tissue smear, culture or biopsy characteristics. Smear and culture is
difficult and possible only in a small number of patients [3,7]. CSF shoes low glucose,
elevated protein, lymphocitic pleocytosis and in some cases acid-fast bacilli can be
identified in smears. CSF culture and polymerase chain reaction (PCR) provide definite
diagnosis [3,7,8]. Radiographic examination of suspected CNS TB begins with computed
tomography Fig. 1 on page 5 (CT) and magnetic resonance imaging (MRI), and up
to 30% of patients have TB features on conventional chest radiography [3] Fig. 2 on page
5.

Page 4 of 25
Images for this section:

Fig. 1: Thorax CT in patient with known SNC TB.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 5 of 25
Fig. 2: 28 year old female with chronic use of adalimumab for rheumatoid arthritis
presented with neurological deterioration and was diagnosed with CNS TB. Chest
radiography shows cavitation in left upper lobe and nodular opacity in right middle lobe.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 6 of 25
Findings and procedure details

Early diagnosis and treatment are essential for prognosis, this makes noninvasive
imaging modalities cornerstone in the approach of suspected CNS TB. We review the
most common spectrum of imaging findings in patients that have presented in our
institution in 2018. These presented with the following:

• · Non parenchymal involvement.

• · Parenchymal involvement.
• · Spinal involvement.

Non parenchymal involvment:

Meningeal involvement is the most common manifestation of TB in the CNS in the

pediatric age group. The most common and specific manifestation is exudates in the
basal cisterns, characteristically in the perimesencephalic, suprasellar, and prepontine
cisterns, along the sylvian sutures, and along the convexities of the brain [3, 7, 10].
Computed tomography findings may be non-specific such as hydrocephalus and as
disease progresses iso/hyper dense exudates that show homogenous enhancement
on administration of contrast material Fig. 4 on page 9 . Magnetic resonance
imaging shows increased signal intensity on T2WI and FLAIR and marked linear and/
or nodular meningeal enhancement on Gadolinium enhanced T1WI. Focal or diffuse
pachymeningitis usually seen mainly in the context of chronic meningeal TB it is
appreciated as plaque like and focal thickening isointense on T1WI iso/hypointensa on
T2WI and intense homogenous enhancement on Gadolinium enhanced T1WI Fig. 8 on
page 12 . Contrast enhanced FLAIR is also of aid in detecting meningeal tuberculous
disease Fig. 9 on page 13 Fig. 10 on page 14 [7, 10, 11,12].

Parenchymal involvement:

Tuberculous granuloma known as tuberculoma is the most common parenchymal lesion

in CNS TB, usually located in the corticomedulary junction and periventricular region, they
may be solitary or multiple and be accompanied or not by meningeal involvement [4, 7,
10, 11]. CT usually show small iso to hyperdense round or lobulated lesions with variable
perilesional edema. Contrast enhanced CT typically demonstrate ring like enhancement
but can also show nodular homogeneous to irregular nonhomogeneous enhancement
with irregular walls of varying thickness Fig. 11 on page 15 . Up to a third of the
patients can present with a central calcification surrounded by ring enhancement known
as the "target sign". [2, 5, 6, 7, 11]. MRI findings of the tuberculoma can be variable
depending on the stage of caseation and liquefaction [11]. Non caseating lesions present
as iso to hypointense on T1WI and hyperintense on T2WI and present with a nodular

Page 7 of 25
homogeneous enhancement on contraste (Gadolinium) administration. Solid caseating
lesions are the most common finding appearing as iso to hypointense in T1WI and
hypointense on T2WI. Caseating lesions with liquefaction show similar T1 findings but
appear hyperintense on T2WI. Both show rim enhancement on contrast administration
Fig. 12 on page 15 Fig. 13 on page 15 [7, 9, 10, 11]. Vasogenic edema seen on
T2WI and FLAIR is variable and can be seen in all lesions.

Miliary brain TB is defined as multiple lesions measuring less than 2-3 mm spread
throughout the parenchyma usually in the corticomedullary junction and can be
associated with meningeal involvement. They are a result of hematogenous spread
usually seen in severely immunocompromised patients. They appear hyperintense on
T2WI with homogenous enhancement on gadolinium enhanced T1WI Fig. 14 on page
16 [6, 11].

TB brain abscess is an infrequent complication arising in less than 10% of patients with
TB. They present as large (>3 cm) multiloculated ring enhancing lesions with important
perilesional edema Fig. 15 on page 17 Fig. 16 on page 17 , presenting restricted
diffusion on diffusion weighted imaging [6, 11].

Spinal involvement:

Spinal involvement is the most common osseous manifestation of TB, it usually affects
the lower thoracic and upper lumbar spine. The disease begins in the anterior part of
the vertebral body with progressive vertebral body destruction but relative sparing of the
intervertebral disc [11, 13]. Posterior vertebral elements are rarely affected [2]. Paraspinal
involvement and paravertebral abscess are common findings, usually affecting the psoas
muscles Fig. 17 on page 18 [6]. CT is recommended in evaluation of osseous
destruction and demonstration of bone fragments in adjacent soft tissue Fig. 18 on page
19 . MRI is more sensitive seen as hypointense with reduced disk height on T1WI,
increased signal intensity on T2WI/STIR, and rim enhancement Fig. 19 on page 20
[5, 6, 10, 11].

Page 8 of 25
Images for this section:

Fig. 3: Hydrocephalus with ventricular dilation in patient with known CNS TB.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 9 of 25
Fig. 4: Hyperdense exudates in basal cisterns. Nodular hyperdense lesion in relation to
a tuberculoma is also observed.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 10 of 25
Fig. 5: Dilation of supra and infra tentorial ventricular system and tonsillar herniation.
Meningeal enhancement is appreciated on contrast enhanced T1WI.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Fig. 6: Axial magnetic resonance imaging shows increased signal intensity on T2WI
and FLAIR along the basal cisterns and marked meningeal enhancement on Gadolinium
enhanced T1WI.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 11 of 25
Fig. 7: Gadolinium enhanced T1WI demonstrates pia-arachnoid enhancement extending
into the subarachnoid spaces between the cerebellar folia in a patient with miliary CNS
TB.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 12 of 25
Fig. 8: Focal dural enhancement adjacent to tuberculous abscess.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 13 of 25
Fig. 9: Mixed meningeal enhancement comparison of contrast enhanced T1WI and
FLAIR. Post contrast FLAIR has been proposed as superior to contraste enhanced T1WI
in defining and detecting meningeal disease.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Fig. 10: Post contrast FLAIR aids in diagnosis of meningeal disease. It is routinely used
in our institution in patients with suspected CNS TB.

Page 14 of 25
© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Fig. 11: NECT shows round hyperdense lesions with perilesional edema. Contrast
enhanced CT demonstrates ring like enhancement. Meningeal involvement is also
appreciated.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Fig. 12: Multiple nodular lesions show ring enhancement. Adjacent dural enhancement
is also observed. T2WI shows important edema and mass effect of lesions.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 15 of 25
Fig. 13: DWI and ADC in same patient show diffusion restriction.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 16 of 25
Fig. 14: Patient with multiple lesions spread throughout the brain parenchyma with
associated with meningeal involvement. They appear hyperintense on T2WI with
homogenous enhancement on gadolinium enhanced T1WI.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Fig. 15: Multiloculated ring enhancing lesions with important perilesional edema.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 17 of 25
Fig. 16: FLAIR imaging of multiloculated ring enhancing lesions with important
perilesional edema.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 18 of 25
Fig. 17: Coronal and sagital contrast enhanced CT images show large left psoas abscess
in patient with tuberculous spondylitis.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 19 of 25
Fig. 18: Same patient with bone window shows vertebral destruction of T12.
Heterogeneous left psoas abscess is observed.

© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Fig. 19: Same patient MRI T1WI, STIR, CET1WI show T12 vertebral collapse, abnormal
signal intensity in STIR and rim enhancement.

Page 20 of 25
© IMSS, Hospital de Especialidades del Centro Médico Nacional Siglo XXI - Ciudad de
México/MX

Page 21 of 25
Conclusion

Tuberculosis is a multi-spectrum disease in all its presentations and the CNS this is no
exception. Clinical history and presentation of disease is important in differentiating from
multiple differential diagnosis. CT and MRI are the imaging modalities of choice, at first
to come to a diagnosis then to define the limits of tuberculous extension.

Page 22 of 25
Personal information

Department of Radiology, Hospital de Especialidades "Dr. Bernardo Sepulveda

Gutierrez" Centro Medico Nacional Siglo XXI, Ciudad de Mexico, Mexico. Avenida
Cuahutemoc 330 Col. Doctores 06720.

Dr. Berenice Zavala Patoni

Magnetic Resonance Imaging Section, Department of Radiology, Department of

Radiology, Hospital de Especialidades "Dr. Bernardo Sepulveda Gutierrez" Centro
Medico Nacional Siglo XXI, Ciudad de Mexico, Mexico.

Email: quinn_bere_nice@hotmail.com

Dr. Jaime de Jesus Iuit Rivera

Magnetic Resonance Imaging Section, Department of Radiology, Department of

Radiology, Hospital de Especialidades "Dr. Bernardo Sepulveda Gutierrez" Centro
Medico Nacional Siglo XXI, Ciudad de Mexico, Mexico.

Email: jaimeiuit@gmail.com

Dr. Adriana Paola Lopez Centeno

Magnetic Resonance Imaging Section, Department of Radiology, Department of

Radiology, Hospital de Especialidades "Dr. Bernardo Sepulveda Gutierrez" Centro
Medico Nacional Siglo XXI, Ciudad de Mexico, Mexico.

Email:adriana_paola@hotmail.com

Dr. Abril Elena Maciel Fierro

Computer Tomography Section, Department of Radiology, Department of Radiology,

Hospital de Especialidades "Dr. Bernardo Sepulveda Gutierrez" Centro Medico Nacional
Siglo XXI, Ciudad de Mexico, Mexico.

Page 23 of 25
Email: abrilele_maciel@hotmail.com

Dr. Miguel Angel Cruz

Resident in training, Department of Radiology, Department of Radiology, Hospital de

Especialidades "Dr. Bernardo Sepulveda Gutierrez" Centro Medico Nacional Siglo XXI,
Ciudad de Mexico, Mexico.

Email: macruz1988@gmail.com

Dra. Araceli Trejo Hernandez

Resident in training, Department of Radiology, Department of Radiology, Hospital de

Especialidades "Dr. Bernardo Sepulveda Gutierrez" Centro Medico Nacional Siglo XXI,
Ciudad de Mexico, Mexico.

Email:aracelihdzt@gmail.com

Dra. Zaira Michelle Flores Reyna

Resident in training, Department of Radiology, Department of Radiology, Hospital de

Especialidades "Dr. Bernardo Sepulveda Gutierrez" Centro Medico Nacional Siglo XXI,
Ciudad de Mexico, Mexico.

Email: zmichelle2101@gmail.com

Page 24 of 25
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