Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
Affiliated with Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
Clin Neurol Neurosurg. 2023 Feb;225:107593. doi: 10.1016/j.clineuro.2023.107593. Epub 2023 Jan 16.
Intracranial tuberculomas are infrequent with a lower morbidity and mortality compared to tubercular meningitis. Giant intracranial tuberculomas are rarer but important differentials for intracranial space-occupying lesions causing focal neurological deficits depending on anatomical location and size.
Histopathologically confirmed giant intracranial tuberculomas selected based on institutional size criteria (<12 Years-old: ≥25 mm; 12-18 Years-old: ≥35 mm; ≥18 Years-old: ≥40 mm) were retrospectively reviewed and analyzed for clinical features, radiology, surgical management, and outcomes in patients admitted from 2015 to 2022.
Ten patients were included (Males:Females = 3:7; Age: 8-68 Years, Average: 30.1 Years). Mean duration of symptoms was 2.84 months. Two patients demonstrated active systemic tuberculosis. Previous tubercular infections included pulmonary involvement in four, meningeal in three, and a cerebellar tuberculoma in one patient. Cerebrospinal fluid analysis in five patients demonstrated no tubercle bacilli. Seven lesions were supratentorial and three infratentorial. Giant tuberculomas demonstrated profound T2 hypointensity, sub-marginal T2 hyperintense crescents, and significant perilesional vasogenic edema. Craniotomy and excision were mainstay except in one case treated only with ventriculoperitoneal shunting. Three additional patients underwent ventriculoperitoneal shunting for hydrocephalus. One patient died from aspiration pneumonia and sepsis following a postoperative seizure. Anti-Tubercular Therapy (ATT) was advised for 18 months. Follow up ranged from 4 to 18 months. One patient was medically managed for ATT-induced hepatitis, hepatic encephalopathy, and coincidental paradoxical reaction. Remainder of patients showed complete resolution of symptomatology and absence of new symptoms till latest follow up.
Clinical course of giant tuberculomas differ from non-giant variants in characteristic radiology, more intensive ATT, and possibility for partial debulking/excision.
与结核性脑膜炎相比，颅内结核瘤发病率较低，死亡率较低。巨大颅内结核瘤则更为罕见，但根据解剖位置和大小，是颅内占位性病变导致局灶性神经功能缺损的重要鉴别诊断之一。
根据机构大小标准（<12 岁：≥25mm；12-18 岁：≥35mm；≥18 岁：≥40mm），选择经组织病理学证实的巨大颅内结核瘤进行回顾性研究和分析，纳入 2015 年至 2022 年期间入院的患者的临床特征、影像学、手术管理和结果。
共纳入 10 例患者（男：女=3：7；年龄：8-68 岁，平均年龄：30.1 岁）。症状平均持续时间为 2.84 个月。2 例患者存在活动性全身结核病。既往结核感染包括 4 例肺部受累、3 例脑膜受累和 1 例小脑结核瘤。5 例患者的脑脊液分析未发现结核分枝杆菌。7 个病灶位于幕上，3 个病灶位于幕下。巨大结核瘤在 T2 上表现为明显的低信号，边缘下 T2 高信号新月形，以及显著的瘤周血管源性水肿。除 1 例仅行脑室-腹腔分流术外，开颅切除术是主要的治疗方法。另外 3 例患者因脑积水行脑室-腹腔分流术。1 例患者术后因癫痫发作并发吸入性肺炎和脓毒症死亡。建议接受 18 个月的抗结核治疗（ATT）。随访时间为 4 至 18 个月。1 例患者因 ATT 引起的肝炎、肝性脑病和并发的矛盾反应而接受药物治疗。其余患者的症状均完全缓解，且在最新随访时未出现新的症状。
巨大结核瘤的临床病程与非巨大变异型不同，其影像学特征更具特征性，ATT 更强化，且可能需要部分去瘤或切除。
