Computed Tomography in Cranial Tuberculosis

HILTON I. PRICE’ AND ALAN DANZIGER1

Twelve patients with proven tuberculosis were studied by

computed tomography. Three had tuberculomas and nine had
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tuberculous meningitis. Although a definite diagnosis is often

not possible on CT, the method Is of value In determining
number, location and extent of lesions. In patients with tuber-
culous meningitis, CT is helpful In assessing the degree of
hydrocephalus and In evaluating the effectiveness of antitu- Fig. 1.-Tuberculous menin-
gitis in 5-year-old boy. Obstruc-
berculous therapy.
tive hydrocephalus with dilated
temporal and frontal horns of
Although the overall incidence of tuberculosis of the lateral ventricles and dilatation
of third ventricle.
central nervous system has declined, it remains an im-
portant disease process in many parts of the world.
Tuberculosis may affect any part of the nervous system
acutely on chronically, focally or diffusely. Tuberculous
meningitis and tuberculoma are the two most important
manifestations of tuberculosis of the central nervous
system. This paper documents the features of these two
conditions on computed tomography (CT).

Case Material

Twelve patients with documented central nervous sys-

tom tuberculosis were examined with an EMI scanner
using a 160 x 160 matrix. All but one of the 12 were
South African Bantu (Negro). The 11 patients with intra-
cranial tuberculosis were scanned with 13 mm collima-
tons; the patient with a retnoorbital tuberculoma was
scanned with 8 mm collimators. lodinated contrast ma-
tenial was used routinely in patients with suspected
tuberculomas. Children under 10 years of age were
sedated with a combination of vesperaxette suppository
and oral Vallergan forte (tnimeprazine tartrate) based on
the child’s weight.

Tubercuious Meningitis
Fig. 2. -Tuberculoma in young
Nine of the 12 patients had tubenculous meningitis. girl. A, Well defined low density
area adjacent to left lateral yen-
None of these nine had associated evidence of tubercu- tricle. B, Homogeneous en-
lomas. Tuberculous meningitis results from the hema- hancement of left lateral ventri-
cle with iodinated contrast me-
togenous dissemination of bacilli from a primary tuber-
dia. Note associated hydroceph-
culosis lesion in the thorax, abdomen, or genitouninary alus. C, Marked
reduction in size
tract. It affects mainly the very young and the very old, and in enhancement after 6
months of antituberculous thor-
with the highest incidence in the first 3 years of life [1]. apy.
In the majority of patients, the disease evolves gradually.
Prodromal symptoms include apathy, anorexia, vomit-
ing, and headache. The headache becomes more intense
and prolonged, and neck stiffness develops. There may
be photophobia, irritability, fever, convulsions, stupor,
coma, and decerebrate rigidity. Cranial nerve dysfunc- specific findings are almost pathognomonic. These
tions, such as sudden onset of a unilateral or bilateral changes reflect, respectively, the basilar fibninous pach-
cranial nerve palsy on sudden catastrophic cerebral on ymeningitis and the vasculitis that characterize this dis-
spinal neurologic deficits, in association with these non- ease process [2].

Received September 8, 1977; accepted after revision December 19, 1977.

‘Department of Diagnostic Radiology, Johannesburg General Hospital, Klein Street, Hospital Hill, Johannesburg, South Africa. Address reprint
requests to A. Danziger.

Am J Roentgenol 130:769-771, AprIl 1978 769 0361 -803X/78/0400 - 0769 $02.00

© 1978 American Roentgen Ray Society
 770 PRICE AND DANZIGER

Fig. 4.-Retroorbital tubercu-

loma. Large retroorbital high
density mass with bony destruc-
tion of lesser wing of sphenoid
and extension into ethmoid si-
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nuses (arrows). No appreciable

change after administration of
iodinated contrast medium.

Fig. 3.-Cystic tuberculoma in 40-year-old male. A, No discernable

The initial CT appearance is that of a low density or
area of focal abnormality. B, Irregularly enhancing high density area in
right side of posterior fossa after administration of iodinated contrast high density lesion which can be very well defined (fig.
material (arrows). Note associated hydrocephalus. 2A) or virtually indistinguishable from the surrounding
parenchyma (fig. 3A). Because of their size, they may
Some authors [3] have been able to visualize gnanu- displace adjacent structures on cause an obstruction to
lomatous tissue involving the base of the brain in such the ventricular system.
conditions as bacterial meningitis by using iodinated After the administration of iodinated contrast medium,
contrast media. We expected to be able to delineate one patient demonstrated a marked homogeneous en-
basilar adhesions in tuberculous meningitis by these hancement of the lesion (fig. 2B). This would be ex-
means. Only three of our patients were scanned with pected in a lesion with an abundance of granulation
iodinated contrast medium (60% solution of meglumine tissue. However, this is not necessarily true in every
iothalamate, 1 mi/kg). No enhancement was demon- tubenculoma. In another patient (fig. 3B) there was
strated, which may relate to the relatively low dose of marked irregular contrast enhancement, representing a
contrast medium. cystic-type tubenculoma. One patient with a tuberculoma
All our patients had varying degrees of obstructive underwent repeat CT study after antituberculous then-
hydrocephalus (fig. 1). In the three patients who had apy. There was a marked reduction in the size and
follow-up scans after institution of antitubenculous then- enhancement of the lesion (fig. 2C).
apy, there was no demonstrable improvement in the One patient had a netroonbital tuberculoma with a
degree of hydnocephalus. large netroonbital high density lesion causing a mild
Calcification has been described in up to 48% of proptosis, destruction of the lessen wing of the sphenoid
patients with this disorder who survive more than 15 and medial orbital wall, and extension of the mass into
months after the onset of disease [15]. All of our patients the ethmoid sinuses. There was no appreciable change
were scanned soon after the commencement of symp- after the administration of iodinated contrast medium
toms, and no calcification was demonstrated. (fig. 4).
About 60% of tuberculomas are described as being
Tuberculoma multiple and supratentonial [8] ; cerebellar tubenculomata
A tuberculoma is a hand, rounded, oval or lobular are usually single lesions. Calcification is described in
mass. The capsule is 1-3 mm thick, gray. gelatinous and 1%-6% of tuberculomas [2]; none of our lesions showed
tough. There is a narrow zone of grayish gliotic tissue this feature.
around it. The center may be necrotic, and there may be
surrounding cerebral edema [10]. Tuberculomas may be REFERENCES
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