Evaluation of cerebral infarction in tuberculous meningitis by diffusion weighted imaging

doi:10.1016/j.jinf.2008.07.012

Journal of Infection

Volume 57, Issue 4, October 2008, Pages 298-306

https://doi.org/10.1016/j.jinf.2008.07.012 Get rights and content

Summary

Background

Ischemic complications are known to occur in tuberculous meningitis (TBM). They are usually seen in patients with TBM having a more severe disease. Diffusion weighted imaging (DWI) provides information regarding tissue ischemia at an early stage as compared to conventional magnetic resonance imaging (MRI).

Methods

Ischemic complications in human immunodeficiency virus (HIV) negative TBM were evaluated using DWI and T2 weighted imaging in 30 patients in the present study. The imaging was performed at baseline within 7 days of admission and in case of any neurological deterioration during follow up. The outcome was assessed by the modified Barthel's index at 1 year follow up. A score of ≥12 was taken as a poor outcome, while a score of <12 was considered as good outcome.

Result

Seventeen of these 30 patients had infarcts, and the total number of infarcts seen was 42. Thirty eight lesions were acute/sub acute and four were chronic infarcts. Out of the 38 acute/sub acute infarcts 34 were visible both on T2 weighted imaging and on DWI, while four were seen only on DWI. The volume of infarcts as seen by DWI was significantly larger as compared to conventional T2 weighted imaging (p = 0.019). Six patients had a poor outcome, five from the infarct group and one from the non-infarct group.

Conclusion

DWI demonstrates a larger area of infarction and may also be useful in the early detection of infarction. It should be used as an additional sequence along with conventional imaging in patients with TBM while they are on a follow up on anti tuberculous treatment. The information obtained by DWI may be of value in explaining the clinical condition of the patient as well as in the management and prognostication.

Introduction

Tuberculosis is the most common cause of chronic meningitis which affects not only meninges but also parenchyma and vasculature of the brain.¹ The role of neuroimaging in tuberculous meningitis (TBM) is in the diagnosis and follow up of the complications. Abnormal meningeal enhancement in basal cisterns, hydrocephalus and vascular complications are common findings on imaging. Magnetic resonance imaging (MRI) shows higher number of hemorrhagic and non-hemorrhagic infarcts, meningeal enhancement and granulomas than computed tomography (CT).¹ There are numerous published studies on tuberculous meningitis, its complications and on prognostic factors.2, 3, 4, 5, 6, 7

Ischemic involvement of small and medium sized vessels at the base of the brain is a common complication in TBM. Majority of infarcts are in the basal ganglia and internal capsule region. The hemorrhagic transformation of infarcts is commonly noticed in TBM.⁸ Ischemic involvement in tuberculous meningitis has been evaluated by multiple modalities including angiography, CT, color Doppler, and MRI. So far many MRI based studies utilizing conventional spin echo sequences, fluid attenuated inversion recovery (FLAIR) or contrast enhanced T1 weighted sequence have been published on the evaluation of ischemia in tuberculous meningitis.9, 10, 11, 12, 13, 14 In English literature there is no prospective study with a 1 year follow up on the evaluation of ischemia in tuberculous meningitis by diffusion weighted MR imaging.

Diffusion weighted MRI provides unique information regarding the viability of tissue, and is particularly sensitive for the detection of acute ischemia as alteration of diffusion coefficient of the cerebral tissue is the first change that can be observed on MRI after an ischemic event. Stejskal and Tanner provided an early description of DWI sequence in 1965 using spin echo T2 weighted pulse sequence.¹⁵ Advancement in MRI techniques has made DWI possible in clinical practice. It has been used to detect infarct at an early stage in stroke patients.¹⁶ There are a number of studies about the role of DWI in tuberculoma and other central nervous system (CNS) infections.17, 18, 19 With the exception of a few isolated case reports mainly in bacterial meningitis there is no prospective study of DWI in tuberculous meningitis.20, 21, 22, 23, 24, 25, 26 DWI may differentiate stroke from other causes of deterioration in the neurological status in TBM patients. This study was planned with the aim of quantitatively evaluating the ischemic component in tuberculous meningitis and to compare abnormality on diffusion weighted MR imaging with conventional T2 weighted MR imaging.

Section snippets

Study design and participants

A prospective observational study was conducted between August 2003 and April 2005 at the Department of Neurology, King George's Medical University, Lucknow in association with the Departments of Radiodiagnosis, Neurology and Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow.

Thirty newly diagnosed HIV negative TBM patients were enrolled over a period of 9 months with a 1 year follow up. The study was approved by the Institutional Ethics Committee and written

Demographic data

Age of the patients ranged from 14 to 56 years with a mean age of 28.7 years. The duration of illness ranged from 0.5 to 15 months with a mean duration of illness of 3.9 months. Headache was the presenting symptom in all the 30 patients (100%), fever in 26 patients (87%), hemiparesis in seven patients (23%) and altered sensorium in six patients (20%). Visual symptoms like diplopia, diminution of vision and complete blindness were present in 11 patients (36%). Fifteen patients were in MRC

Discussion

The findings of the present prospective study involving DWI and other conventional MRI sequences show that 17 out of 30 (56.7%) patients had infarcts. This is in agreement with the observation of Gupta et al.³³ who performed MRI and MR angiography in 26 patients of TBM and reported infarcts in 53.8%. On the other hand Chang et al. observed ischemic involvement in only 40% of the patients out of 15 cases of acute TBM and five cases of chronic TBM in whom MRI and CT scan were done.³⁴ Koh et al.

Conclusion

The present study is the first of its kind which provides useful preliminary data regarding the role of DWI in evaluating ischemic complications of patients with TBM. It also suggests that DWI has an advantage over conventional T2 weighted imaging. Amongst various MR imaging techniques, DWI gives a better depiction of the size of the infarcted cerebral tissue. However, further larger case series are required to define the relationship between DWI appearance, neurological deficit and clinical

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This result is probably due to the use of MRI instead of CT as in the previous research. MRI with diffusion-weighted imaging (DWI) is, in fact, far more sensitive than CT in detecting acute strokes, especially the smaller ones, and subacute strokes with T2 and FLAIR sequences [10–12]. Cerebral infarction is a common manifestation of TBM and probably the most devastating.
Magnetic resonance imaging (MRI) is largely used in the diagnosis of central nervous system involvement of tuberculosis (CNSTB), yet there is no MRI comparison study between HIV+ and HIV− patients with CNSTB. The aim of the present study was to identify MRI differences in CNSTB between HIV+ and HIV− patients and possibly find early characteristics that could raise the suspect of this disease.
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Tuberculous meningitis is associated with significant risk of neurological complications and death in the United States.
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View full text

Evaluation of cerebral infarction in tuberculous meningitis by diffusion weighted imaging

Summary

Background

Methods

Result

Conclusion

Introduction

Section snippets

Study design and participants

Demographic data

Discussion

Conclusion

J Neurol Sci

J Neurol Sci

Radiol Clin N Am

Comput Med Imaging Graph

J Clin Neurosci

Neuroimaging Clin N Am

Eur J Radiol

Pediatr Neurol

Clin Imaging

Eur J Radiol

Lancet

Tuber Lung Dis

J Neurol Sci

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Tuberculous meningitis in adults – experience from Turkey

Int J Clin Pract

Tuberculous meningitis in a district hospital from southern Ethiopia

Ethiop Med J

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Int J Tuberc Lung Dis

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J Trop Pediatr