Al-Edrus SA, Shahizon AMM, Norzaini R, Sobri M THE DIFFERENT FACES OF CENTRAL NERVOUS SYSTEM TUBERCULOSIS: A PICTORIAL REVIEW Al-Edrus SA, Shahizon AMM, Norzaini R, Sobri M

Tuberculosis (TB), an infection caused by Mycobacterium tuberculosis is an infectious disease that continues to be a significant health problem and is responsible for 8 million annual deaths worldwide. Involvement of the central nervous system remains it’s most severe form and is responsible for a high morbidity and mortality. The radiological features are remarkably diverse and may involve any part of the brain, spinal cord and their coverings.

Intramedullary tuberculoma Myelitis Spine: Spondylitis Discitis Parenchyma: Tuberculoma Tucerculous abcess Miliary TB Vascular: Vasculitis Infarction Haemorrhage Calvarium Meninges: Leptomeninges Pachymeninges Ventricles: Hydrocephalus Ventriculitis Cord and meninges: Leptomeningitis Arachnoiditis Spinal exudate Intramedullary tuberculoma Myelitis Spine: Spondylitis Discitis Paraspinal collection

Calvarium: Sagittal T2WI Sagittal T1WI-post Gd Isolated involvement of the calvarium is extremely rare and are usually seen in children. In this case, it isa 66 y.o man with left lower limb weakness and numbness. MRI showed a destructive lesion involving the right fronto-parietal bone. There is also an enhancing extradural soft tissue mass compressing onto the right fronto-parietal lobe involving the premotorcortex, which would explain his presenting symptoms. Noted also is a subgaleal collection. Sagittal T2WI Sagittal T1WI-post Gd

Post treatment Sagittal T1WI Sagittal T1WI post Gd Following 4 months of anti tuberculous therapy, there is still minimal signal change seen in the involved bone. However,there is complete resolution of the extradural soft tissue mass and subgaleal collection. Sagittal T1WI Sagittal T1WI post Gd

Tuberculoma Axial T2WI Axial FLAIR Tuberculomas are space occupying masses of granulomatous tissue which can be single or usually multiple. Symptoms depend on the site involved and number of lesions..In this case, we see multiple round hypointense.in the region of the basal meninges. Surrounding white matter oedema is also present. Axial T2WI Axial FLAIR

Axial T1WI Post Gd Sagittal T1WI Post Gd These lesions demonstrate avid enhancement Axial T1WI Post Gd Sagittal T1WI Post Gd

Depending on the stage of granulation, lesions can either be non caseating, caseating with a solid centre or caseating with liquid centre, which would be reflected in different MRI appearances. White arrow: Non caseating. Blue: Caseating with a solid centre. Red: Caseating with a liquid centre

Miliary tuberculosis Axial T2WI Axial T1WI Miliary tuberculosis are usually associated with TBM. They are less than 2mm in size and may not be visible in conventional spine echo MR as evidenced by this case. They can also be seen as tiny foci of hyperintensity on T2. In certain cases perilesional oedema may be absent. Axial T2WI Axial T1WI

Axial T1WI Post Gd Sagittal T1WI Post GD Lesions are best appreciated in the post Gadolinium images. Axial T1WI Post Gd Sagittal T1WI Post GD

Tuberculous abcess Axial T2WI Coronal FLAIR Tuberculous abcess constitutes 4-7% of CNS TB in developing countries. Presents as solitary large lesion. They are frequently multiloculated with significant surrounding oedema and mass effect. Axial T2WI Coronal FLAIR

Multiloculations are best seen in the post contrast images which will also demonstrate ring enhancement. Sagittal T1WI Post Gd

Axial T1WI Post Gd Coronal T1WI Post Gd

Leptomeningeal tuberculosis Leptomeningeal TB may involve the brain, spinal cord or both as seen in the patient here. Intracranially, meningeal enhancement is typically seen in the basal cisterns. T1 MPR Post Gd

Pachymeningeal tuberculosis Isolated involvement of the dura or pachymenigitis is different from involvement of the dura which is adjacent to a TB abcess or tuberculoma. It may exist as a focal or diffuse involvement of the dura and may be the result of haematogenous spread of the bacilli. T1 MPR post Gd

Ischaemic infarct Axial T2WI Coronal FLAIR Cerebral infarction secondary to TBM occurs in about in up to 41% of TBM patients. It can occur in the acute stage or later stages of infection. Several mechanisms are implicated in their development: 1) Vassels traversing the basal exudates, resulting in vasculitis, spasm, constriction and thrombosis. 2) Meningeal inflammatory exudate involving adventitia and leading to necrotizing panarteritis with thrombosis and occlusion and 3) dilated ventricles stretching already compromised vessels,leading to infarction. Axial T2WI Coronal FLAIR

Morbidity and mortality in patients with infarction secondary to TBM are high. The majority of infarctions occur in the basal ganglia, internal capsule and thalamus. Areas of infarction demonstrate restricted diffusion with corresponding low signal on ADC. Axial DWI Axial ADC

Note the subtle enhancement of the infarcted area as well as numerous enhancing tuberculomas within the brain parenchyma. Post Gd

Haemorrhagic infarct Axial T2WI Sagittal T1WI Haemorhhagic infarct can also occur in TBM. In this case, the area haemorrhagic infarct involve the rostrum and genu of the corpus callosum. Axial T2WI Sagittal T1WI

Axial T1WI Post Gd Coronal T1WI Post Gd On the post contrast images, we can also see numerous enhancing miliary tubercles and leptomeningeal enhancement along the pial surface of the brainstem and upper cervical cord. Axial T1WI Post Gd Coronal T1WI Post Gd

Tuberculous vasculitis Axial T1WI Post Gd

Axial Gradient Echo Axial T2WI

Axial Gradient Echo Axial T2WI

Tuberculous myelitis Sagittal T2WI Sagittal T1WI Imaging features of TB myelitis are similar to that of cerebritis. The involved cord appears expanded with a hyperintense signal on T2 Sagittal T2WI Sagittal T1WI

Sagittal T2WI Sagittal T1WI

Contrast enhancement of the involved areas are the rule Contrast enhancement of the involved areas are the rule. Although the abnormal hyperintense signal on T2 may subside after several weeks, the contrast enhancement may persist for several months. Sagittal T1WI Post Gd

Intramedullary tuberculoma Similar to intracranial tuberculomas, intramedullary tuberculomas are granulomatous lesions which can be single or multiple within the spinal cord. T2WI T2 STIR T1WI

Axial T1WI Post Gd Sagittal T1WI Post Gd Unlike TB myelitis, lesions are smaller, less congruent and more numerous. In the above images, multiple small areas of enhancement are seen within the spinal cord in the thoracic and lumbar region.

Tuberculous CSF exudate T1WI T2WI T2 STIR

T1WI Post Gd T2WI

T1WI Post Gd T1WI

Spinal TB: paraspinal and subligamentous abcess Tuberculous involvement of the spine is very common and involves one or more component of the extradural component of the spine. The vertebral bodies are most commonly involved. The posterior elements, epidural space, paraspinal soft tissue and intervertebral discs are more commonly secondararily involved or can be the primary site of involvement. In the above images, multiple vertebral body involvement are seen with surrounding abcess collection. T1WI T2WI T2 STIR

Post Gd Ax Paraspinal and subligamentous extension of tuberculous spinal abcess are common and may extend along several vertebral body lengths. Sag Cor

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