Diagnostic & Prognostic Features of Complicated Tuberculous Meningitis on CT Scanning. (A two years study in Neurosurgery Unit of Tertiary Care Hospital.)

Background: Tubercular meningitis is dreadful sequel of extra pulmonary tuberculosis which often complicate to involve neurosurgeon in management. Neurosurgeon rely on CT brain for management of tubercular meningitis and its complications. There are many changes visible on CT brain in TBM patient which need to be explained in terms of its clinical significance and prognosis.

Objectives: To asses tubercular meningitis CT scan findings and discuss their significance in diagnosis and prognosis of tubercular meningitis.

Material & Methods:This observational descriptive study was conducted at department of neurosurgery Hayatabad Medical Complex Hospital Peshawar from sept,2017 to august,2019. Tuberculous meningitis patients of age range 16 to 60 years of either gender were included in this study. All those patients having space occupying lesion other than tuberculoma in brain and other causes of meningitis were excluded from this study. All the diagnosed tubercular meningitis admitted patients were subjected to CT brain with contrast and CT brain findings were noted along with clinical assessment and clinical improvement of patient to standardised in-patient care, till patient gets discharged and upto 9 month follow up period(9months ATT completion). The cases of TBM were divided according to standard Lincolin et al grading scale into three stages.The data was analyzed with the help of SPSS version 22.Effect modifiers were stratified and and post stratification Chi-Square test was applied with P-value < 0.05 as significant.

Results: In this study there were total (50) patients of TBM with mean age of (36.21±07.53) years. There were 24 (48%) males and 26 (52%) females. Maximum cases were seen in stage II of TBM which affected 32 (64%) cases. Hydrocephalus was seen in 31 (62%) of the cases as shown in table 01. Hydrocephalus was significantly high in female gender 20 (76.92%) as compared to males 12 (24%)with p value of 0.03 as in table I. Radiological features visible on CT scan as shown in table 2 are ventricular enlargement 32(64%)patients, periventricular luscencies 28(56%), basal enhancement 15(30 %), basal lusency 17 ( 34%),peripheral infarction19(38 %),and in 14 (28 %) no abnormality. Ventriculomegaly is the most common abnormality in the CT brain but periventricular lucency is the poor prognostic finding visible on CT Brain.

Conclusion: Hydrocephalus is a common complication of TBM and it is frequently seen in females ,2nd and 3rd decades of life and stage 2/stage 3 of TBM.Timely management leads to a better outcome. vetriculomegaly along with sub-ependymal hypodensity is poor prognostic indicator.

Key words: TBM ,Hydrocephalus, Meningitis.

Received: August’2020   Accepted: Oct’2020

 

INTRODUCTION:

 

Tuberculosis (TB) is a disease of the ancient times and still it exists, About 2000 million people in the world today are infected with tuberculosis1. The number are highest in the developing countries and its incidence rate is 275 per 100,000 population in Pakistan according to World Health Organization1.Tuberculosis usually involves lungs but it can involve any part of the body.It can involve brain in the form of meningitis, encephalitis and tuberculoma2.TBM was elaborated as distinct clinical problem in 19362 caused by mycobacterium tuberculosis.

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Hydrocephalus is a common complication of

TBM and it is frequently seen in females at 2nd

and 3rd decades of life and stage 2 and 3 of TBM.

Timely management leads to a better outcome.

vetriculomegaly along with sub-ependymal hypodensity

is poor prognostic indicator.

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The uncertainity of variable clinical presentations dilemmas of diagnosis and wide variety of complications pose a big problem in management of TBM . Delayed diagnosis and missed treatment can result in fatal outcomes3. The pathophysiology of neurological complications of TBM is via three mechanisms Adhesion formation, basal vasculitis and encephalitis11. Inflammatory exudates accumulate and settle in subarachnoid Basal cisterns to block csf pathways which in turn causes hydrocephalus to develop, since brain vessels are end arteries the inflammatory vasculitis causes ischaemia macro and micro infarcts12,13. The clinical presentation of TBM is variable. Diagnosis on clinical grounds is not possible. The prodrome is usually non specific,28% report headache,25% vomiting,13% had fever. Only 2% reported meningitis symptoms are quoted in literature14,15. The neurological complications that can occur are cranial nerves palsies(3rd,4th,6th,7th,8th) and hydrocephalus. Hydrocephalus presents with signs and symptoms of raised ICP like Headache, Nausea/Vomiting, Decreased conscious level and sometimes seizures16. Infarcts occur in about 30% of cases commonly in the internal capsule and basal ganglia causing a range of disorders from hemi-paresis to movements disorders17.

 

 

Advances in CT MRI has clarified ambiguities in diagnosis of TBM and helped in early diagnosis of various complications of TBM19. Tuberculomas appear as ring enhancing lesion with surrounding edema, may be single or multiple .Basal meningeal enhancement is more pronounced in MRI brain. The major role of neuroradiology has been in management and in particular in the diagnosis and follow up of those complications requiring neurosurgery consultation20. Treatment of uncomplicated TBM is chemotherapy with ATT. The role of neurosurgeon starts with neurological complication in a patient which is being treated conservatively. There are several causes of this and require radiological assessment. The prevalence of hydrocephalus ranges from 20-65%3-4.The data from Pakistan has shown its range from 58% in a study from Rawalpindi to 72.3% in Karachi.5-6 However one study from India on 45 cases revealed this hydrocephalus in 33.3 % of cases only7.Prompt assessment by CT brain is mandatory both for early diagnosis prognosis and management. Studies suggest that prompt ventriculo-peritoneal shunting improve outcome24. Rationale of conducting his study is to define important radiologic changes seen on CT brain in advanced stage tuberculous meningitis patients and its possible link to prognosis after standard management.

 

MATERIALS AND METHODS:

 

This was an observational descriptive study with non probability consecutive sampling technique. This study was conducted at department of Neurosurgery Hayatabad Medical Complex Hospital Peshawar from 1st Sept ,2017 to 31st august,2019.The cases of tuberculous meningitis of age range of (16 to 60) years of either gender were included in this study. The cases with bacterial meningitis, having any SOL in brain and those with any previous history of brain surgery were excluded from this study. The diagnosis of TBM and hydrocephalus was made on the basis of combination of clinical features, laboratory investigations and CT/MRI brain. Patient with clinical suspicion of hydrocephalus were screened through CT brain and then MRI brain for more detailed description. All the patients diagnosed as hydrocephalus were treated by Ventriculo-peritoneal shunt and post operative ATT for one year. Follow up neuro-imaging was done after 6 months. The cases of TBM were divided according to standard Lincolin et al grading scale into three stages only patients in stage 2,and 3 were subjected to CT brain due to advanced disease .The data was analyzed with the help of SPSS version 22. Effect modifiers were stratified and post stratification Chi-Square test was applied with P-value < 0.05 as significant.

 

RESULTS:

 

In this study there were total (50) patients of TBM with mean age of (36.21±07.53) years. There were 24 (48%) males and 26 (52%) females. Maximum cases were seen in stage II of TBM which affected 32 (64%) cases. Hydrocephalus was seen in 31 (62%) of the cases as shown in table 01. Hydrocephalus was significantly high in female gender 20 (76.92%) as compared to males 12 (24%)with p value of 0.03 as in table I. Radiological features visible on CT scan as shown in table 2 are ventricular enlargement 32(64%)patients, periventricular luscencies 28(56%), basal enhancement 15(30 %), basal lusency 17 ( 34%),peripheral infarction19(38 %),and in 14 (28 %) no abnormality. As shown in figure 1 ventriculomegaly is the most common abnormality in the CT brain but periventricular lucency accounts for the highest mortality 4deaths and no change/no improvement in clinical status of 7 patients despite maximum standard treatment and ventriculoperitoneal shunting. Hence ventriculomegaly along with periventricular lucency is the bad prognostic finding visible on CT Brain.

 

 

 

 

DISCUSSION:

 

Tuberculosis continues to be a a major health problem for developing and poor countries. One third of world population are infected with mycobacterium tuberculosis4.Hydrocephalus is the most common complication of TBM .It is almost always present in patients who have had the disease for four to six weeks. Shoeman at al found the hydrocephalus was 65% in his study24. In our study we found 64% patients that are diagnosed with TBM developed hydrocephalus. It is more frequent and severe in children and early adulthood21.This has been seen in our study too, where the majority of patients in early adulthood (16-29) years showed post TBM hydrocephalus. Hydrocephalus was significantly high in female gender(76.92%) as compared to males where it affected 12 (24%) of cases with p value of 0.03. on the other hand male gender was proved as a risk factor for the development of hydrocephalus in cased of TBM by previous studies. Kumar and Christensen AS et al found that males were seen in more than 2/3rd cases of TBM; though this difference was not statistically significant with p values of 0.54 and 0.34 resepctively12-13.Hydrocephalus was also significantly high in cases with stage II and III of TB affecting 43.75% and 56.25% of cases respectively with p= 0.01.The studies have shown that there is liner association of the severity of the disease and the development of the hydroecephalus.14-15 Chan et al in their study found 89% of the cases to develop hydrocephalus in cases of TBM.11 The reason can be explained by the fact that the severe the disease and higher is the turbidity of the CSF and led to difficult drainage and ultimately led to hydrocephalus. Hydrocephalus in patients could be either of non obstructive type or obstructive type25,the former being more common. This has been demonstrated in our study too showing (63.9%) patients communicating type hydrocephalus. The clinical features that pointing towards the presence of HCP are nonspecific. In any patient with Tuberculous meningitis with signs of raised ICP, hydrocephalus should be suspected even if papilloedema could not be visualized and these patients should be subjected to neuro-radiologic examination. Hydrocephalus can also be suspected in patients who have very minimal symptoms of raised ICP. Although a widely used classifying system exists for patients with TBM, namely lincolin et al grading system, a distinct grading system did not exist for patients with TBM and hydrocephalus. Another proposed grading system for TBM and hydrocephalus is (Vellore grading system) based on the presence or absence of neurological deficits and level of sensorium15. Although some researchers studied Conservative management of some communicating hydrocephalus to reduce the rate of vp shunt surgeries in TBM cases but early VP shunting of TBM meningitis give good patient outcome in terms of patient hospital stay and ultimate neurological outcome. However medical management implies continuous monitoring of patients. Patients with obstructive hydrocephalus and acute deterioration need urgent shunt surgery as delayed treatment lead to poor outcome. . Radiological features visible on CT scan as shown in table 2 are ventricular enlargement 32(64%)patients, periventricular luscencies 28(56%), basal enhancement 15(30 %), basal lucency 17 ( 34%),peripheral infarction19(38 %), and in 14 (28 %) no abnormality. As shown in table 3 ventriculomegaly is the most common abnormality in the CT brain but periventricular lucency accounts for the highest mortality 4deaths and no change/no improvement in clinical status of 7 patients despite maximum standard treatment and ventriculo-peritoneal shunting. Hence ventriculomegaly along with periventricular lucency is the bad prognostic finding visible on CT Brain. Outcome of surgery depends on clinical factors like age,duration of illness,sensorium of patients.Biochemical factors predicting outcome are CSF protein count, CSF cell count,Basal lucencies ,subependymal leaks are also predictors of poor outcome21.

 

CONCLUSION:

 

Hydrocephalus is a common complication of TBM and it is frequently seen in females ,2nd and 3rd decades of life and stage 2/stage 3 of TBM. Timely management leads to a better outcome. vetriculomegaly along with sub-ependymal hypodensity is poor prognostic indicator.

 

 

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2. Necrotizing anterior scleritis

 

A woman suffering from rheumatoid arthritis complained with a 1-month history of pain in the eye. She had already stopped immunosuppressive treatment a few years earlier. There was no history of trauma. Slit-lamp examination showed hyperemia, inflammation, and marked scleral thinning with exposure of underlying choroid.

 

Differential diagnosis

 

Necrotizing anterior scleritis, Posterior scleritis, Hyphema,Conjuctival hemorrhage, Acute angle closure glaucoma

 

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