van Dellen A, Nadvi S S, Nathoo N, Ramdial P K
Department of Neurosurgery, University of Natal Medical School and Wentworth Hospital, Durban, South Africa.
Neurosurgery. 1998 Aug;43(2):370-3. doi: 10.1097/00006123-199808000-00118.
Many types of neurotuberculosis have been described; the most common intracranial forms are tuberculous meningitis and tuberculomas. We report a unique and as yet unreported form of neurotuberculosis, which is an intracranial tuberculous subdural empyema.
A 59-year-old man who had been previously treated for pulmonary tuberculosis (TB) presented at our institution with a long-standing history of headaches. General and neurological examinations revealed no abnormalities. Radiography of the chest confirmed fibrotic lung changes caused by healed pulmonary TB. A cranial computed tomographic scan revealed a hypodense extra-axial collection with mass effect as well as adjacent osteitis and scalp swelling.
The patient underwent craniectomy of the osteitic bone and drainage of 50 ml of fluid pus located subdurally. Microscopic examination of the bone and pus revealed tuberculous granulation tissue with numerous acid-fast bacilli identified using Ziehl-Neelsen stain. Mycobacterium TB bacillus was cultured from the pus at 42 days. The patient required two further operative procedures as well as a protracted course of anti-TB therapy.
The patient eventually achieved a good recovery. We recommend surgical drainage of tuberculous subdural empyema to relieve mass effect and to obtain microbiological confirmation. Furthermore, surgical treatment should be combined with an 18-month course of anti-TB chemotherapy, during which period patient compliance should be closely monitored.
已描述了多种类型的神经结核；最常见的颅内形式是结核性脑膜炎和结核瘤。我们报告一种独特且尚未报道过的神经结核形式，即颅内结核性硬脑膜下积脓。
一名曾接受过肺结核治疗的59岁男性因长期头痛前来我院就诊。全身及神经系统检查未发现异常。胸部X线检查证实有陈旧性肺结核导致的肺部纤维化改变。头颅计算机断层扫描显示轴外低密度占位并有占位效应，以及相邻骨质炎和头皮肿胀。
患者接受了骨炎部位颅骨切除术，并引流了硬脑膜下50毫升脓性液体。对骨质和脓液进行显微镜检查发现结核性肉芽组织，用齐-尼氏染色法鉴定出大量抗酸杆菌。42天时从脓液中培养出结核分枝杆菌。患者还需要另外两次手术以及长期的抗结核治疗疗程。
患者最终恢复良好。我们建议对结核性硬脑膜下积脓进行手术引流以减轻占位效应并获得微生物学确诊。此外，手术治疗应与18个月的抗结核化疗疗程相结合，在此期间应密切监测患者的依从性。
