Findings
Axial DWI, ADC, T2/FLAIR, axial & coronal T1 post contrast images reveal a well-defined heterogeneous T2 hyperintense lesion showing thick peripheral enhancing wall, central diffusion restriction in left temporal lobe (a,b,d) with pachymeningeal enhancement along left temporal region and left mastoiditis (e,f). Moderate adjacent vasogenic edema is seen causing mass effect in the form of compression of adjacent lateral ventricle, effacement of overlying sulcal spaces, subfalcine herniation and contralateral midline shift (c). MR spectroscopy (j) reveals elevated lipid lactate peak. Thin leptomeningeal enhancement (i) is seen along basal cisterns. Acute non-hemorrhagic infarct is seen in left posterior parietal, occipital and medial temporal lobes (g,h).
Diagnosis
Tubercular meningitis (TBM), abscess and meningovasculitis with left PCA territory acute infarct
Summary
Intracranial vasculitis is common in the patients with TBM. Cerebral infarction is an important complication of TBM affecting up to two-thirds of the patients and is associated with poor outcomes. TB predominantly causes exudates along the basal surface of the brain and adjacent cisternal spaces; however, the majority of the infarcts are in perforator arteries of both the anterior and posterior circulation. Autopsy studies have also shown extensive vasculitis in TBM involving both the proximal vessels of the circle of Willis and distal perforator branches.
Further reads
Vanjare, Harshad Arvind1,; Gunasekaran, Karthik2; Manesh, Abi3; Mishra, Ajay Kumar4; Mannam, Pavithra1; Iyadurai, Ramya2; Jasper, Anitha1; Mani, Sunithi5. Evaluation of Intracranial Vasculitis in Tuberculous Meningitis using Magnetic Resonance Vessel Wall Imaging Technique. International Journal of Mycobacteriology 10(3):p 228-233, Jul–Sep 2021. | DOI: 10.4103/ijmy.ijmy_117_21
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