Sadashiva Nishanth, Tiwari Sarbesh, Shukla Dhaval, Bhat Dhananjaya, Saini Jitender, Somanna Sampath, Devi Bhagavatula Indira
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, 2nd Floor, Neurosciences Faculty Building, Bangalore, 560029, India.
Department of Neuroimaging & Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, India.
Acta Neurochir (Wien). 2017 May;159(5):889-897. doi: 10.1007/s00701-017-3108-1. Epub 2017 Feb 11.
Isolated brainstem tuberculomas are rare lesions and account for up to 5% of all intracranial tuberculomas in endemic areas. The difficulties in diagnosis and management of this condition are sparsely reported. The aim of this study is to illustrate the nuances in managing brainstem tuberculomas, define prognosis, and demonstrate a shift in management strategies with newer imaging modalities.
A retrospective review of 14 patients diagnosed and treated with a diagnosis of 'isolated brainstem tuberculoma' between 2011 and 2015 was done. Diagnosis was made after combining the findings at clinical history, examination, as well as imaging features. Patients were treated with steroids for 6 weeks or until they made a meaningful clinical recovery, and antitubercular therapy (ATT) for a minimum of 18 months or until there was resolution of the tuberculoma. Confirmation of tubercular pathology was done by observing if response to treatment resulted in clinical improvement, which happened in all of our cases.
Mean age at diagnosis was 24.7 years and nine were males. Twelve patients had a combination of cranial nerve deficits with pyramidal weakness or sensory symptoms. Mean duration of symptoms was 4.7 months and tests for human immunodeficiency virus (HIV) infection were negative in all patients. Only two patients had a previous history of tubercular meningitis. Most lesions were located in the pons with size ranging from 1 to 22.2 cm. Eight patients showed complete resolution of the lesion at latest follow-up and the rest were still on ATT. Mean duration of ATT received for resolution of the lesion was 22 months. Almost all of our patients improved clinically on steroids and ATT.
Intracranial tuberculomas may present with or without meningitis. A high index of suspicion is essential, especially in endemic areas. A combination of clinical symptoms, investigations, and imaging features help in coming to a diagnosis. Biopsy of a brainstem lesion is fraught with complications. Antitubercular therapy has a very good prognosis, though the duration of therapy required may be longer.
孤立性脑干结核瘤是罕见病变，在流行地区占所有颅内结核瘤的比例高达5%。关于这种疾病诊断和治疗的困难鲜有报道。本研究的目的是阐述脑干结核瘤治疗的细微差别，明确预后，并展示随着更新的影像学模式管理策略的转变。
对2011年至2015年间诊断并治疗为“孤立性脑干结核瘤”的14例患者进行回顾性研究。结合临床病史、检查及影像学特征做出诊断。患者接受6周的类固醇治疗或直至临床有显著恢复，以及至少18个月的抗结核治疗（ATT）或直至结核瘤消退。通过观察治疗反应是否导致临床改善来确认结核病理，我们所有病例均如此。
诊断时的平均年龄为24.7岁，9例为男性。12例患者合并有脑神经功能缺损及锥体束征或感觉症状。平均症状持续时间为4.7个月，所有患者的人类免疫缺陷病毒（HIV）感染检测均为阴性。只有2例患者既往有结核性脑膜炎病史。大多数病变位于脑桥，大小从1至22.2厘米不等。8例患者在最新随访时病变完全消退，其余患者仍在接受抗结核治疗。病变消退接受抗结核治疗的平均持续时间为22个月。几乎所有患者在接受类固醇和抗结核治疗后临床症状改善。
颅内结核瘤可伴有或不伴有脑膜炎。高度的怀疑指数至关重要，尤其是在流行地区。临床症状、检查及影像学特征相结合有助于做出诊断。脑干病变活检充满并发症。抗结核治疗预后良好，尽管所需治疗时间可能较长。
