CASE 14249 Published on 20.11.2016

Cerebral TB



Case Type

Clinical Cases


Dr Ahmed Ali, Dr Muhammad Khan, Dr Shahid Hussain

Birmingham Heartlands hospital; Bordesley Green E, Bordesley Green, Birmingham, United Kingdom, B9 5SS.

25 years, male

Area of Interest Head and neck ; Imaging Technique MR
Clinical History
A 25-year-old male presented with fever, headache and confusion. MRI head revealed multiple ring enhancing lesions mainly affecting the cerebellum. The patient developed diplopia shortly after – 6th nerve palsy. Repeat MRI head showed a right caudate infarct and several new ring enhancing lesions.
Imaging Findings
Pulmonary washings in this patient grew Mycobacteria Tuberculosis (TB).

Initial MRI head with contrast - multiple tuberculomas mainly affecting the cerebellum (figures 1 and 2).

Repeat MRI head - high signal on fluid attenuation inversion recovery (FLAIR) images in the right head of caudate nucleus, anterior limb of internal capsule extending into anterior aspect of the right basal ganglia. (Figures 3). The abnormality is of high signal on the true diffusion images (figure 4) and reduced signal on the apparent diffusion coefficient (ADC) images (figure 5). This is a complication of TB vasculitis.

Computed tomography (CT) thorax - widespread miliary nodularity in both lung apices with some cavitation infiltrates (Figure 6 and 7).
The World Health Organisation ranks TB as the world’s most deadly infectious disease with an estimated 1.4 million deaths in 2015 [1]. 10% of TB patients develop central nervous system (CNS) involvement. This risk is even higher in patients who have AIDS related TB [2-4]. Radiological findings may mimic other infective, non-infective and malignant pathologies. It can take on various forms ranging from tuberculomas and meningitis to spinal and calvarial involvement [5-7].

TB meningitis is a common form of CNS involvement. Leptomeningeal enhancement and enhancing exudates in the Fossa interpeduncluaris are considered sensitive and specific signs of TB meningitis respectively [6, 8, 9]. Findings are better appreciated on post contrast MR imaging compared to CT [5].
Parmar et al. demonstrated FLAIR images to be more specific when compared to contrast-enhanced T1 weighted images in detecting meningeal enhancement [10].

The most common intracranial radiological lesion in CNS TB is a tuberculoma which can present with or without co-existent meningeal involvement [11]. It is usually seen as a lesion with ring like enhancement with little surrounding oedema.

A clinician must be aware of the potential complications of CNS TB which include vasculitis, infarction, hydrocephalus and cranial neuropathies [6, 7]. As in this case, paradoxical enlargement of a pre-existing tuberculoma or development of a new tuberculoma in patients on adequate treatment may be seen. With continued treatment these eventually resolve [12, 13].
Differential Diagnosis List
• CNS Tuberculosis• Pulmonary Tuberculosis
Cerebral abscess
Final Diagnosis
• CNS Tuberculosis• Pulmonary Tuberculosis
Case information
DOI: 10.1594/EURORAD/CASE.14249
ISSN: 1563-4086