Kolakshyapati Manish, Takeda Masaaki, Mitsuhara Takafumi, Yamaguchi Satoshi, Abiko Masaru, Matsuda Shingo, Kurisu Kaoru
Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
Neurospine. 2018 Sep;15(3):277-282. doi: 10.14245/ns.1836034.017. Epub 2018 Aug 28.
Central nervous system tuberculosis is a devastating complication of systemic tuberculosis. Intradural extramedullary (IDEM) tuberculoma at the foramen magnum is rare, and mimics en plaque meningioma. We report the case of a 53-year-old woman who presented with dysesthesia of the tongue and lower cranial nerve (CN) palsy, with onset 4 months prior to admission. The neurologic examination revealed left upper-limb weakness and hypoesthesia on the sole and dorsum of the left foot. Other physical examinations revealed no features of tubercular infection. Laboratory investigations likewise showed no signs of infection or inflammation. Magnetic resonance imaging of the brain showed an IDEM mass originating from the left intradural surface at the foramen magnum extending to the C2 segment and compressing the brainstem and upper cervical cord. The mass was isointense/hypointense on T1- and T2-weighted images and homogeneously-enhanced on postcontrast images. The lesion also exhibited the dural-tail sign and was preoperatively diagnosed as en plaque meningioma. The patient underwent surgery via the left transcondylar fossa approach with partial laminectomy of the atlas. Intraoperatively, the mass exhibited a dural origin and encased the vertebral artery and lower CNs, with strong adhesions. While the histopathological study of the mass was strongly suggestive of tuberculoma with multifocal granulomas, caseous necrosis, and Langerhans giant cells, extensive diagnostic studies failed to detect Mycobacterium tuberculosis itself. Although the patient had recurrence with multisystem involvement, she responded well to antitubercular treatment. IDEM tuberculoma of the foramen magnum may present as en plaque meningioma. Histopathology is required for a definitive diagnosis. Prompt surgical resection and decompression with adequate antitubercular treatment yield better neurological outcomes.
中枢神经系统结核是系统性结核的一种严重并发症。枕骨大孔处硬膜内髓外（IDEM）结核瘤罕见，易误诊为斑块状脑膜瘤。我们报告一例53岁女性病例，患者在入院前4个月出现舌感觉异常和下颅神经（CN）麻痹。神经系统检查发现左上肢无力，左脚底和脚背感觉减退。其他体格检查未发现结核感染的特征。实验室检查同样未显示感染或炎症迹象。脑部磁共振成像显示一个IDEM肿块，起源于枕骨大孔左侧硬膜内表面，延伸至C2节段，压迫脑干和颈髓上段。该肿块在T1加权和T2加权图像上呈等信号/低信号，增强后图像上均匀强化。病变还表现出硬膜尾征，术前诊断为斑块状脑膜瘤。患者通过左经髁窝入路并进行寰椎部分椎板切除术。术中，肿块显示为硬膜起源，包裹椎动脉和下颅神经，粘连紧密。虽然肿块的组织病理学研究强烈提示为结核瘤，有多灶性肉芽肿、干酪样坏死和朗汉斯巨细胞，但广泛的诊断研究未能检测到结核分枝杆菌本身。尽管患者出现多系统受累的复发情况，但她对抗结核治疗反应良好。枕骨大孔处的IDEM结核瘤可能表现为斑块状脑膜瘤。明确诊断需要组织病理学检查。及时进行手术切除和减压并给予充分的抗结核治疗可取得更好的神经功能预后。
