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Cerebral tuberculoma and

magnetic resonance imaging

A Helmy1
1

NM Antoun2 PJ Hutchinson1

Neurosurgery Unit, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital,

Cambridge, UK
2

Department of Neuroradiology, Addenbrookes Hospital, Cambridge, UK

Correspondence to: A Helmy. Email: adelhelmy@cantab.net

DECLARATIONS
Competing interests
None declared

This case highlights an unusual presentation of

cerebral tuberculosis (TB) and the associated radiological findings on MRI, including diffusionweighted imaging.

Case report
A 17-year-old Indian man presented with a twomonth history of left-sided headache, morning

Funding
AH is supported by a
joint Medical
Research Council/
Royal College of
Surgeons of England

Figure 1
Preoperative MR imaging. a d. Four contiguous slices on T1WI following the injection of gadolinium,
demonstrating the extent of the original lesions. e. A T2WI illustrating the extent of white matter high
signal intensity indicative of cerebral oedema. f. A diffusion-weighted image: it does not show restricted
diffusion (high signal) within the two lesions that would be expected within a liquid abscess

Clinical Research
Training Fellowship
and a Raymond and
Beverly Sackler
Fellowship; PJH is
supported by the
Academy of Medical
Sciences/Health
Foundation
Fellowship
Ethical approval
Written informed
consent to
publication has been
obtained from the
patient or next of kin
Guarantor
PJH
Contributorship
AH conducted the
research and
literature review and
wrote the first draft;

J R Soc Med 2011: 104: 299 301. DOI 10.1258/jrsm.2011.100398

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299

Journal of the Royal Society of Medicine

PJH was responsible

for the clinical
aspects and
overseeing the
paper; NMA was
responsible for
neuroradiology; all
authors contributed
to the final draft of
the paper
Acknowledgements
None
Reviewer
Phillip vanHille

vomiting, visual disturbance and bilateral papilloedema. On direct questioning the patient noted
6 kg of weight loss in the prior six months. On
referral to the acute neurosurgical service MR
imaging was carried out. Following the injection
of gadolinium the lesions enhanced peripherally
on T1-weighted image (T1WI) with multiple
smaller enhancing lesions associated with the
main lesions (Figure 1a d). Two well-defined
(3.5 cm) low signal lesions were demonstrated on
T2-weighted image (T2WI), in the left frontoparietal and right occipital regions, with marked
surrounding oedema (Figure 1e). The diffusionweighted MR sequence did not demonstrate
restricted diffusion (Figure 1f ), as would be
expected of a liquid abscess.1 Chest X-ray was
normal and laboratory findings were as follows: haemoglobin 12.7 g/dl, white cell count 5.9 109/L,
C-reactive protein 20 mg/L. There was no laboratory

Figure 2
Follow-up MR imaging at three months. a d. The same four slices as
in Figures 1a d on T1WI following the injection of gadolinium. The
operated (left parietal) lesion has completed disappeared. The
non-operated (right occipital) lesion has significantly decreased in
size reflecting a good response to medical therapy

300

J R Soc Med 2011: 104: 299 301. DOI 10.1258/jrsm.2011.100398

or clinical evidence of an immunocompromised

state.
In view of the mass effect caused by the left
fronto-parietal lesion and the uncertain diagnosis
the patient underwent an emergent image-guided
craniotomy and excision of the left-sided lesion.
At craniotomy a hard, well-circumscribed lesion
was identified with a similar colour to normal
white matter. Histology confirmed cerebral tuberculoma, as evidenced by granuloma formation
and a single acid-fast bacillus. Subsequent chest
CT identified pulmonary TB. The patient commenced anti-tuberculous triple therapy with
Rifater, moxifloxacin, pyridoxine and dexamethasone.2 At three-month follow-up his presenting
symptoms and papilloedema had resolved and
he was gaining weight. Repeat MR imaging at
this point demonstrated complete surgical excision of the parietal lesion and a reduction in the
size of the occipital lesion with reduced oedema
suggestive of a response to pharmacological
therapy (Figure 2).

Discussion
The global incidence of TB is increasing, even
in the immunocompetent population.3 Central
nervous system TB is most common in those
aged below 20 years (60 70% of cases), and coexistent extra-neural TB is only reported in 50%
cases, as in this case.4 Central nervous system TB
most commonly takes the form of meningeal
disease (leptomeningitis or more rarely pachymeningitis) as well as the parenchymal disease
described here (tuberculous granuloma [tuberculoma], tuberculous abscess, focal cerebritis and
allergic tuberculous encephalopathy)5. The
most common clinical presentation of a tuberculoma is headache, signs of intracranial hypertension, focal neurological deficit and seizure.
Tuberculous meningitis is characterized radiologically by the triad of basal meningeal
enhancement, hydrocephalus and cerebral infarction, though a range of other features are
common.5 Cerebral tuberculomas are most
common at the cortico-medullary junction,
especially in the frontal and parietal lobes, as
they are often the result of haematogenous
spread as part of miliary TB.6 Diffusion-weighted
MR is a useful adjunct in abscesses as the central

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Cerebral tuberculoma and magnetic resonance imaging

portion of an abscess will demonstrate restricted

diffusion however this is not the case in a true
tuberculoma.5
Follow-up imaging following appropriate antituberculous pharmacotherapy allows the response
to therapy to be gauged, with the degree of contrast enhancement and surrounding oedema
related to the activity within the tuberculoma.7 A
high index of clinical suspicion is required to
allow rapid diagnosis of this condition in order
to institute rapid treatment and avoid potentially
serious neurological sequelae.

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