Brain MRI findings in relation to clinical characteristics and outcome of tuberculous meningitis

Abstract

Neuroradiological abnormalities in tuberculous meningitis (TBM) are common, but the exact relationship with clinical and inflammatory markers has not been well established. We performed magnetic resonance imaging (MRI) at baseline and after two months treatment to characterise neuroradiological patterns in a prospective cohort of adult TBM patients in Indonesia. We included 48 TBM patients (median age 30, 52% female, 8% HIV-infected), most of whom had grade II (90%), bacteriologically confirmed (71%) disease, without antituberculotic resistance. Most patients had more than one brain lesion (83%); baseline MRIs showed meningeal enhancement (89%), tuberculomas (77%), brain infarction (60%) and hydrocephalus (56%). We also performed an exploratory analysis associating MRI findings to clinical parameters, response to treatment, paradoxical reactions and survival. The presence of multiple brain lesion was associated with a lower Glasgow Coma Scale and more pronounced motor, lung, and CSF abnormalities (p-value <0.05). After two months, 33/37 patients (89%) showed worsening of MRI findings, mostly consisting of new or enlarged tuberculomas. Baseline and follow-up MRI findings and paradoxical responses showed no association with six-month mortality. Severe TBM is characterized by extensive MRI abnormalities at baseline, and frequent radiological worsening during treatment.

Fig 1. Common baseline MRI findings in adults with tuberculous meningitis.

Meningeal enhancement at basal meninges (A), right Sylvian fissure (B), and ventricular (C); non-miliary and miliary tuberculomas (D); pseudo abscess in axial DWI (E1), axial ADC (E2), axial T2 FLAIR (E3) and axial T1W1 post contras (E4); multiple acute infarctions at the left basal ganglia in axial DWI (F1), axial ADC (F2), and axial T2 FLAIR (F3); Communicating hydrocephalus with narrowed Callosal angle (G), void signal in the aqueduct (H), and dilated temporal horn (I), broader of Evans’ ratio (J); and oculomotor nerve enhancement (K).

Fig 2. Paradoxical response with basal meningeal enhancement after 60 days treatment.

Basal meningeal exudate before (A) and after two months after anti-tuberculosis drugs (B). Both from T1-W1 post contras from one patient with radiological worsening at day 60 days after anti-tuberculosis treatment.