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Intracranial tuberculomas
INTRACRAN1AL
TUBERCULOMAS
H. G6kalp, E. Ozkal and B. Tiimer*
SUMMARY In this paper the clinical findings, operation results and histological diagnosis of eight patients with intracranial tuberculomas are described, which were admitted to the Neurosurgical Clinic of Ankara University, Faculty of Medicine, during the years 1967-1975, among the 1,015 histologically verified intracranial tumours. Our impression by reviewing previous papers on this matter is, that although tuberculomas are not so frequently seen as before, they still count as a certain percentage in Turkey.
INTRODUCTION M a n y years ago intracranial t u b e r c u l o m a s constituted a high percentage o f intracranial t u m o u r s . F o r instance, in 1889 STARR recorded 5 0 ~ o f the i n t r a c r a n i a l t u m o u r s in children and in 1933 GARLAND a n d ARMITAGE stated 34 ~o o f the intranial t u m o u r s to be t u b e r c u l o m a s , a c c o r d i n g to their a u t o p s y findings (THRUSH a n d BARWICK, 1974). D u r i n g the following years this ratio decreased. In 1940, from a total o f 2,190 brain t u m o u r s Wilson notified only 3.6~o and in 1972, from a total o f 2,200 brain t u m o u r s MORRIS WILLIAMSnotified only 0,15 ~o as t u b e r c u l o m a s (THRUSH and BARWICK, 1974). In u n d e r - d e v e l o p e d countries and also in some E u r o p e a n countries, the ratio is higher. In S o u t h - A m e r i c a , it was 8 ~ (ASENJO et al., 1951) and in I n d i a 20~o (OBRADOR 1973, RAMAMURTHI a n d VARADARAJAN, 1973). Even t h o u g h in T u r k e y the percentage decreases, it still retains a certain percentage o f intracranial t u b e r c u l o m a s .
CASES Case 1. A 28 year-old w o m a n with c o m p l a i n t s o f headache, p r o t r u s i o n o f the right eye and visual disturbances over a period o f m o r e than one year, was a d m i t t e d for further clinical observation. * Ankara University, Faculty of Medicine, Neurosurgical Dept., Ankara, Turkey. Clin. Neurol. Neurosurg., Vol. 79-3
229 In her past- and family history there were no abnormalities. Neurological examination revealed exophthalmos, partial third-nerve paralysis on the right and beginning of papilledema. Visual acquity on the left was 0,1 and was very low on the right also. There was a concentric narrowing of the visual field, especially on the right side. No abnormalities were detected on X-rays of the skull and lungs. A deformity on the right optic foramen was observed on the orbital X-rays (fig. 1). EEG-fi.ndings were normal. On the right carotid angiogram an elevation of a part of the proximal anterior cerebral artery was present.
h
.~
Fig. 1.
TREATMENT: By right fronto-temporal craniotomy a tumour, localised around and under the optic chiasma and extending to the orbit was removed. The histological diagnosis was tuberculoma and the patient received tuberculostatics. After two years, vision was improved on both sides. There was a partial improvement of the visual fields also. Case 2. A 35 year-old woman with complaints of headache, seizures of unconsciousness and weakness on the right side, was admitted for further investigation. In her past- and family history there were no abnormalities. By neurological examination a right-sided hemiparesis, hemihypesthesia and early papilledema were detected. The EEG showed a focus of delta activity in the left fronto-temporal region. A left carotid angiogram
230 did not suggest the presence of a tumour. Brain-scanning showed an increased activity compatible with a space occupying lesion of 3 by 3 cm in the left frontotemporal region. TREATMENT: With a left posterior frontal craniotomy, the tumour, localised in the m o t o r cortex, was removed. The histo-pathologic diagnosis was tuberculoma (fig. 2). The patient was further treated with tuberculostatics. She was dismissed with a rightsided hemiparesis, hemihypesthesia and dysphasia. She did not return for further controls. Fig. 2:
Case 3. A 30 year-old man, with complaints of headache, weakness on the right side, and seizures of unconsciousness, which began with a trembling sensation from the right arm, was admitited. The onset of these complaints was 25 days prior to his referral. The patient had been treated for lung-tuberculosis about ten years ago. Neurological examination revealed papilledema, rightsided hemiparesis and dysphasia. On the lung X-rays we detected miliary and focal shadows. The skull X-rays were normal. E E G revealed a focal disturbance in the left fronto-temporal region. On the left carotid angiogram a frontal mass-lesion was observed. TREATMENT: A subcortical solid frontal tumour was totally removed through a left frontal craniotomy. The histological diagnosis was a tuberculoma. The patient was dismissed with tuberculostatics. Four months later he died following an epileptic fit.
231 Case 4. A 24 year-old woman, with complaints of headache and visual disturbances for 20 days was admitted. There were no significant abnormalities in her own- or family past history. Neurological investigation revealed a bilateral papilledema, slight ataxia and a central facial paresis on the right side. Radiological studies of skull and lungs were normal. A left carotid angiogram revealed a parietal tumour image. TREATMENT: A parasagittal tumour was totally removed with a left parietal craniotomy. The histological diagnosis was a tuberculoma and the patient was dismissed with tuberculostatics. Case 5. A 16 year-old man was admitted with complaints of headache and visual disturbances over a period of more than one year. In his past- and family history there were no significant abnormalities. Neurological examination findings were: a papilledema on the right side and an optic atrophy on the left side. Vision was severely decreased on the right side and totally absent on the left side. Radiological studies of the lungs were normal. An enlarged sella, erosion on clinoid processes and diminished sphenoid sinus pneumatisation was seen on plain skull X-rays. A left carotid angiogram revealed an elevation of the proximal anterior cerebral artery and straightening of the carotid syphon. TREATMENT: An arachnoiditis around the optic chiasma was cleared with a right frontal craniotomy. T u m o u r mass extending from the sphenoid sinus was removed and the sinus was cleared. The histological diagnosis was tuberculous granulation tissue (fig. 3 and 4). Post-operatively there was an obvious visual improvement up to 0.5 on the right side; and 0.2 on the left side. He was dismissed with tuberculostatics. Case 6. A 25 year-old woman, with complaints of headache and weakness on the left side for three months, was admitted. There were no significant abnormalities in her family- or her own past history. Neurological examination findings were bilateral papilledema and left hemiparesis. Radiologic findings of the lungs and skull were normal. On a right carotic angiogram there was a suspicious shifting to the left and on brain scanning signs of a probable subdural h a e m a t o m a were observed. With 50 cc air a pneumoencephalogram was performed and a filling defect on the right lateral ventricle was found (fig. 5). TREATMENT: A subcortically localised tumour was totally removed through a right parietal craniotomy. The histological diagnosis was a tuberculoma. Tuberculostatic treatment had started and three months later an obvious improvement in hemiparesis had occured. Case 7. A 38 year-old woman, complaining of headache, visual disturbances, amorosis fugax, and an unstable gait for two months was admitted. There were no significant ab-
232
Fig. 3
Fig. 4
/,
Fig. 5
233 normalities in her family- or her own past history. Neurological examination: bilateral optic atrophy, a right hemiparesis and ataxia. Radiologic findings of the lungs were normal and on the plain X-rays of the skull there were changes in sella due to chronic increased intracranial pressure. A left carotid angiogram revealed a hydrocephalus. The brain scanning was normal. TREATMENT: Ventriculography findings prior to the operation revealed dilation of the lateral ventricles, the third ventricle and an obstruction in the neighbourhood of the aqueductus sylvii. By a posterior fossa exploration, performed in sitting position, two tumours in the left cerebellar hemisphere were removed. The histological diagnosis was tuberculous granulation tissue. She was dismissed with tuberculo statics. Neurological condition after the operation did not improve. Case 8. A 16 year-old man, complaining of headache, weakness on the left side and focal motor seizures on the left hand for two weeks, was admitted. His family- and own past history were normal. Neurological examination: bilateral optic atrophy, vision only light perception on the right side and finger counting from three meters on the left side. He also had a left hemiparesis. Radiological studies of the lungs revealed a calcification near the right hilus. On skull X-rays there was a calcification on the right frontal region (fig. 6). The right carotid angiogram showed a space occupying lesion. In the brain scanning a hyperactivity of 3 cm was demonstrated in the same region.
Fig. 6
234 TREATMENT: The node of 4 by 3 by 3 cm was totally removed through a right frontal craniotomy and lobectomy. The histological finding was a tuberculoma. The patient died on the 29th post-operative day due to a Coli infection of the wound and a meningo-encephalitis.
DISCUSSION: Brain tuberculomas mainly develop from a primary tuberculous focus elsewhere which necessarily does not have to be clinically active. Microscopic or small tuberculomas are frequently seen in patients who previously had a tuberculous meningitis, without any clinical sign (MERRITT, 1973). Tuberculomas can be seen in any age, but generally in the first thirty years of life (ANDERSONand MACMILLAN,1975; MERRITT, 1973; THRUSH and BARWICK, 1974). Our cases are between the ages of sixteen and thirty-eight, the mean age being twenty-three. Tuberculomas can be localised anywhere in the brain. Equal supra and infratentorial distribution (THRUSHand BARWICK, 1974) has been stressed in the literature (ANDERSONand MCMILLAN, 1975). Although in children the majority of the tuberculomas are located in the posterior fossa. In our cases the localisation was as follows: one in the cerebellum, five in the hemispheres and two in the optochiasmatic region (table 1). TABLEI. Localisation of Tuberculomas Case No.
Age
Sex
I
28
F
II
35
F
+
III
30
M
+
IV
24
F
V
16
M
VI
25
F
VII
38
F
VIII
16
M
Total
Frontal
Parietal
Chiasmatic Post. fossa ÷
÷ ÷ ÷ ÷
+ 3
2
2
1
The symptoms and signs of a tuberculoma are those of an intracanial space occupying lesion. A severe headache is always present. The majority of patients develop severe papilledema, in about one half of them secondary optic atrophy causes blindness or severe loss of vision (DASTURand DESAI, 1965; DESCUNSet al., 1954). If it is located in optochiasmatic region as in two of our cases, it may cause primary optic atrophy, similar to the other tumours of this region. Visual disturbances develop
235 early. In four patients visual disturbances were the initial complaints (table 2). Different forms of epilepsy may be seen in 70 to 85 70 of supratentorial tuberculomas (OBRADOR, 1973). In three of the five cases of hemispheric tuberculomas convulsion was one of the early symptoms. We also observed motor weakness as an early symptom in six cases. The duration of symptoms is generally as short as in glial tumours (table 2), mostly between three months and a year (NORTHFIELD,1973). TABLE 2.
Case No. Initial Complaints
I
II
llI
IV
V
VI
VII
VIII
Headaches
+
+
+
+
+
+
q-
+
+
+
Convulsion Visual disturbance
+
Motor weakness Duration of Symp.
+
12 mon.
+
+
+
6 mon.
25 day
20 day
+
12 mon.
+
+
+
+
+
3 mon.
2 mon.
12 day
The clinical diagnosis of tuberculoma is rather difficult, even though the presence of tuberculosis in the past history has been reported in about 5 0 ~ of the cases (DASTUR and DESAI, 1965; RAMAMURTIJIand VARADARAJAN, 1961). This was present in only one case in our series. However, associated tuberculous disease elsewhere in the body or close contact with diseased persons is very important in making a correct diagnosis. Diagnostic procedures do not differ from those in other intracranial space occupying lesion. Radiological investigations are very important. Evidence of an increased intracranial pressure is the prominent finding in plain skull X-rays, which is usually seen in children. Calcification in skull X-rays is not frequently seen. This ratio has been reported (CASTROand LEPE, 1963) as 1.4 ~ , (DASTUR and DESAX, 1965) as 4.770, (ARSENI, 1958) and as 5.570. We have seen this only in one case. Angiography and ventriculography are both useful. If the angiogram shows hydrocephalus indicating posterior fossa lesion then positive contrast ventriculography is done. Regarding the appearance of an avascular space occupying lesion in the angiogram, reasonable vascularisation imitating meningiomas, could also be found in subcortical localised tuberculomas (RAMAMURTHIand VARADARAJAN, 1961). We found that brain scanning is a most useful investigation, also for identifying multiple lesions. The incidence of multiple tuberculomas is variable. In the series of DASTUR and DESAI (1965) consisting of fourteen cases, the lesion is solitary. Incidences of multiple tuberculomas in the series of CASTRO and LEPE (1963) were 1 6 ~ and in ASENJO et al. (1951) 327o. In our cases there was only one case with two nodes in the cerebellum.
236 D i a g n o s i s c a n o n l y be c o n f i r m e d h i s t o l o g i c a l l y .
A p p e a r a n c e d u r i n g the o p e r a t i o n
c o u l d be like a low g r a d e a s t r o c y t o m a , m e t a s t a t i c t u m o u r , a n d also in cases o f d u r a l a d h e s i o n s , t h e r e is a r e s e m b l a n c e to m e n i n g i o m a s . r e d u c e d the m o r t a l i t y rate f r o m 5 0 ~
Treatment with streptomycine
(OBRADORet al., 1973) to 1 0 - 2 0 ~ .
One of our
p a t i e n t s d i e d o f status e p i l e p t i c u s a n d the o t h e r o f p o s t - o p e r a t i c e i n f e c t i o n .
Strep-
t o m y c i n e , P A S a n d I N A H w e r e used as t u b e r c u l o s t a t i c s in o u r cases. S t r e p t o m y c i n e was a d m i n i s t e r e d as l gr per day, t o t a l l y 30 gr, P A S 10-20 gr per d a y a n d I N A H 5-10 m g / k g d u r i n g six to n i n e m o n t h s .
REFERENCES ANDERSON,J. M. and MACMILLAN,J. J.," Intracranial tuberculoma- an increasing problem in Britain. J. Neurol. Neurosurg. Psychiatr. 38: 194, 1975. ARSENI, C . : Two hundred and one cases of intracranial tuberculoma, treated surgically. J. Neurol. Neurosurg. Psychiatr. 21: 308, 1958. ASENJO, A., VALLADARES,H . , and FIERRO,J.: Tuberculomas at the brain. Archives of Neurology and Psychiatry (Chic), 65: 146, 1951. CASTRO,M., and LEPE, A.: Cerebral tuberculoma. Acta Radiologica. Diagnosis 1,821, 1963. DASTUR, H. M., and DESAI,A. D. : A comperative study of brain tuberculomas and gliomas. Brain, 88: 375, 1965. DESCUNS, V., GARRI~,H., PHf:LINE, C.; Tuberculoma of the brain and cerebellum. J. Neurosurg. 2: 243, 1954. GARLANDand ARMITAGE1933: cited by Thrush and Barwick. MERRtTT, H. : A textbook of Neurology, 293, 5th ed. Lea-Febiger, Philadelphia, 1973. NORTHFIELD, D. W. C.." The surgery of the central nervous system, pp. 884, Black Well. Scientific publication, 1973. OBRADOR,S." Neurological Surgery, Vol. 3 1569, 1st ed. W. B. Saunders Company, Philadelphia, 1973. RAMAMURTH1,B. and VARADARAJAN,M. G." Diagnosis of Tuberculomas of the Brain. Clinical and Radiological Correlation. J. Neurosurg. 18: 1-7, 1961. STARR, cited by Thrush and Barwick THRUSH, D. C., and BARWlCK, D D." Three patients with intracranial tuberculomas with unusual features. J. Neurol. Neurosurg. Psychiatr. 37: 566, 1974.
TUBERCULOMAS
H. G6kalp, E. Ozkal and B. Tiimer*
SUMMARY In this paper the clinical findings, operation results and histological diagnosis of eight patients with intracranial tuberculomas are described, which were admitted to the Neurosurgical Clinic of Ankara University, Faculty of Medicine, during the years 1967-1975, among the 1,015 histologically verified intracranial tumours. Our impression by reviewing previous papers on this matter is, that although tuberculomas are not so frequently seen as before, they still count as a certain percentage in Turkey.
INTRODUCTION M a n y years ago intracranial t u b e r c u l o m a s constituted a high percentage o f intracranial t u m o u r s . F o r instance, in 1889 STARR recorded 5 0 ~ o f the i n t r a c r a n i a l t u m o u r s in children and in 1933 GARLAND a n d ARMITAGE stated 34 ~o o f the intranial t u m o u r s to be t u b e r c u l o m a s , a c c o r d i n g to their a u t o p s y findings (THRUSH a n d BARWICK, 1974). D u r i n g the following years this ratio decreased. In 1940, from a total o f 2,190 brain t u m o u r s Wilson notified only 3.6~o and in 1972, from a total o f 2,200 brain t u m o u r s MORRIS WILLIAMSnotified only 0,15 ~o as t u b e r c u l o m a s (THRUSH and BARWICK, 1974). In u n d e r - d e v e l o p e d countries and also in some E u r o p e a n countries, the ratio is higher. In S o u t h - A m e r i c a , it was 8 ~ (ASENJO et al., 1951) and in I n d i a 20~o (OBRADOR 1973, RAMAMURTHI a n d VARADARAJAN, 1973). Even t h o u g h in T u r k e y the percentage decreases, it still retains a certain percentage o f intracranial t u b e r c u l o m a s .
CASES Case 1. A 28 year-old w o m a n with c o m p l a i n t s o f headache, p r o t r u s i o n o f the right eye and visual disturbances over a period o f m o r e than one year, was a d m i t t e d for further clinical observation. * Ankara University, Faculty of Medicine, Neurosurgical Dept., Ankara, Turkey. Clin. Neurol. Neurosurg., Vol. 79-3
229 In her past- and family history there were no abnormalities. Neurological examination revealed exophthalmos, partial third-nerve paralysis on the right and beginning of papilledema. Visual acquity on the left was 0,1 and was very low on the right also. There was a concentric narrowing of the visual field, especially on the right side. No abnormalities were detected on X-rays of the skull and lungs. A deformity on the right optic foramen was observed on the orbital X-rays (fig. 1). EEG-fi.ndings were normal. On the right carotid angiogram an elevation of a part of the proximal anterior cerebral artery was present.
h
.~
Fig. 1.
TREATMENT: By right fronto-temporal craniotomy a tumour, localised around and under the optic chiasma and extending to the orbit was removed. The histological diagnosis was tuberculoma and the patient received tuberculostatics. After two years, vision was improved on both sides. There was a partial improvement of the visual fields also. Case 2. A 35 year-old woman with complaints of headache, seizures of unconsciousness and weakness on the right side, was admitted for further investigation. In her past- and family history there were no abnormalities. By neurological examination a right-sided hemiparesis, hemihypesthesia and early papilledema were detected. The EEG showed a focus of delta activity in the left fronto-temporal region. A left carotid angiogram
230 did not suggest the presence of a tumour. Brain-scanning showed an increased activity compatible with a space occupying lesion of 3 by 3 cm in the left frontotemporal region. TREATMENT: With a left posterior frontal craniotomy, the tumour, localised in the m o t o r cortex, was removed. The histo-pathologic diagnosis was tuberculoma (fig. 2). The patient was further treated with tuberculostatics. She was dismissed with a rightsided hemiparesis, hemihypesthesia and dysphasia. She did not return for further controls. Fig. 2:
Case 3. A 30 year-old man, with complaints of headache, weakness on the right side, and seizures of unconsciousness, which began with a trembling sensation from the right arm, was admitited. The onset of these complaints was 25 days prior to his referral. The patient had been treated for lung-tuberculosis about ten years ago. Neurological examination revealed papilledema, rightsided hemiparesis and dysphasia. On the lung X-rays we detected miliary and focal shadows. The skull X-rays were normal. E E G revealed a focal disturbance in the left fronto-temporal region. On the left carotid angiogram a frontal mass-lesion was observed. TREATMENT: A subcortical solid frontal tumour was totally removed through a left frontal craniotomy. The histological diagnosis was a tuberculoma. The patient was dismissed with tuberculostatics. Four months later he died following an epileptic fit.
231 Case 4. A 24 year-old woman, with complaints of headache and visual disturbances for 20 days was admitted. There were no significant abnormalities in her own- or family past history. Neurological investigation revealed a bilateral papilledema, slight ataxia and a central facial paresis on the right side. Radiological studies of skull and lungs were normal. A left carotid angiogram revealed a parietal tumour image. TREATMENT: A parasagittal tumour was totally removed with a left parietal craniotomy. The histological diagnosis was a tuberculoma and the patient was dismissed with tuberculostatics. Case 5. A 16 year-old man was admitted with complaints of headache and visual disturbances over a period of more than one year. In his past- and family history there were no significant abnormalities. Neurological examination findings were: a papilledema on the right side and an optic atrophy on the left side. Vision was severely decreased on the right side and totally absent on the left side. Radiological studies of the lungs were normal. An enlarged sella, erosion on clinoid processes and diminished sphenoid sinus pneumatisation was seen on plain skull X-rays. A left carotid angiogram revealed an elevation of the proximal anterior cerebral artery and straightening of the carotid syphon. TREATMENT: An arachnoiditis around the optic chiasma was cleared with a right frontal craniotomy. T u m o u r mass extending from the sphenoid sinus was removed and the sinus was cleared. The histological diagnosis was tuberculous granulation tissue (fig. 3 and 4). Post-operatively there was an obvious visual improvement up to 0.5 on the right side; and 0.2 on the left side. He was dismissed with tuberculostatics. Case 6. A 25 year-old woman, with complaints of headache and weakness on the left side for three months, was admitted. There were no significant abnormalities in her family- or her own past history. Neurological examination findings were bilateral papilledema and left hemiparesis. Radiologic findings of the lungs and skull were normal. On a right carotic angiogram there was a suspicious shifting to the left and on brain scanning signs of a probable subdural h a e m a t o m a were observed. With 50 cc air a pneumoencephalogram was performed and a filling defect on the right lateral ventricle was found (fig. 5). TREATMENT: A subcortically localised tumour was totally removed through a right parietal craniotomy. The histological diagnosis was a tuberculoma. Tuberculostatic treatment had started and three months later an obvious improvement in hemiparesis had occured. Case 7. A 38 year-old woman, complaining of headache, visual disturbances, amorosis fugax, and an unstable gait for two months was admitted. There were no significant ab-
232
Fig. 3
Fig. 4
/,
Fig. 5
233 normalities in her family- or her own past history. Neurological examination: bilateral optic atrophy, a right hemiparesis and ataxia. Radiologic findings of the lungs were normal and on the plain X-rays of the skull there were changes in sella due to chronic increased intracranial pressure. A left carotid angiogram revealed a hydrocephalus. The brain scanning was normal. TREATMENT: Ventriculography findings prior to the operation revealed dilation of the lateral ventricles, the third ventricle and an obstruction in the neighbourhood of the aqueductus sylvii. By a posterior fossa exploration, performed in sitting position, two tumours in the left cerebellar hemisphere were removed. The histological diagnosis was tuberculous granulation tissue. She was dismissed with tuberculo statics. Neurological condition after the operation did not improve. Case 8. A 16 year-old man, complaining of headache, weakness on the left side and focal motor seizures on the left hand for two weeks, was admitted. His family- and own past history were normal. Neurological examination: bilateral optic atrophy, vision only light perception on the right side and finger counting from three meters on the left side. He also had a left hemiparesis. Radiological studies of the lungs revealed a calcification near the right hilus. On skull X-rays there was a calcification on the right frontal region (fig. 6). The right carotid angiogram showed a space occupying lesion. In the brain scanning a hyperactivity of 3 cm was demonstrated in the same region.
Fig. 6
234 TREATMENT: The node of 4 by 3 by 3 cm was totally removed through a right frontal craniotomy and lobectomy. The histological finding was a tuberculoma. The patient died on the 29th post-operative day due to a Coli infection of the wound and a meningo-encephalitis.
DISCUSSION: Brain tuberculomas mainly develop from a primary tuberculous focus elsewhere which necessarily does not have to be clinically active. Microscopic or small tuberculomas are frequently seen in patients who previously had a tuberculous meningitis, without any clinical sign (MERRITT, 1973). Tuberculomas can be seen in any age, but generally in the first thirty years of life (ANDERSONand MACMILLAN,1975; MERRITT, 1973; THRUSH and BARWICK, 1974). Our cases are between the ages of sixteen and thirty-eight, the mean age being twenty-three. Tuberculomas can be localised anywhere in the brain. Equal supra and infratentorial distribution (THRUSHand BARWICK, 1974) has been stressed in the literature (ANDERSONand MCMILLAN, 1975). Although in children the majority of the tuberculomas are located in the posterior fossa. In our cases the localisation was as follows: one in the cerebellum, five in the hemispheres and two in the optochiasmatic region (table 1). TABLEI. Localisation of Tuberculomas Case No.
Age
Sex
I
28
F
II
35
F
+
III
30
M
+
IV
24
F
V
16
M
VI
25
F
VII
38
F
VIII
16
M
Total
Frontal
Parietal
Chiasmatic Post. fossa ÷
÷ ÷ ÷ ÷
+ 3
2
2
1
The symptoms and signs of a tuberculoma are those of an intracanial space occupying lesion. A severe headache is always present. The majority of patients develop severe papilledema, in about one half of them secondary optic atrophy causes blindness or severe loss of vision (DASTURand DESAI, 1965; DESCUNSet al., 1954). If it is located in optochiasmatic region as in two of our cases, it may cause primary optic atrophy, similar to the other tumours of this region. Visual disturbances develop
235 early. In four patients visual disturbances were the initial complaints (table 2). Different forms of epilepsy may be seen in 70 to 85 70 of supratentorial tuberculomas (OBRADOR, 1973). In three of the five cases of hemispheric tuberculomas convulsion was one of the early symptoms. We also observed motor weakness as an early symptom in six cases. The duration of symptoms is generally as short as in glial tumours (table 2), mostly between three months and a year (NORTHFIELD,1973). TABLE 2.
Case No. Initial Complaints
I
II
llI
IV
V
VI
VII
VIII
Headaches
+
+
+
+
+
+
q-
+
+
+
Convulsion Visual disturbance
+
Motor weakness Duration of Symp.
+
12 mon.
+
+
+
6 mon.
25 day
20 day
+
12 mon.
+
+
+
+
+
3 mon.
2 mon.
12 day
The clinical diagnosis of tuberculoma is rather difficult, even though the presence of tuberculosis in the past history has been reported in about 5 0 ~ of the cases (DASTUR and DESAI, 1965; RAMAMURTIJIand VARADARAJAN, 1961). This was present in only one case in our series. However, associated tuberculous disease elsewhere in the body or close contact with diseased persons is very important in making a correct diagnosis. Diagnostic procedures do not differ from those in other intracranial space occupying lesion. Radiological investigations are very important. Evidence of an increased intracranial pressure is the prominent finding in plain skull X-rays, which is usually seen in children. Calcification in skull X-rays is not frequently seen. This ratio has been reported (CASTROand LEPE, 1963) as 1.4 ~ , (DASTUR and DESAX, 1965) as 4.770, (ARSENI, 1958) and as 5.570. We have seen this only in one case. Angiography and ventriculography are both useful. If the angiogram shows hydrocephalus indicating posterior fossa lesion then positive contrast ventriculography is done. Regarding the appearance of an avascular space occupying lesion in the angiogram, reasonable vascularisation imitating meningiomas, could also be found in subcortical localised tuberculomas (RAMAMURTHIand VARADARAJAN, 1961). We found that brain scanning is a most useful investigation, also for identifying multiple lesions. The incidence of multiple tuberculomas is variable. In the series of DASTUR and DESAI (1965) consisting of fourteen cases, the lesion is solitary. Incidences of multiple tuberculomas in the series of CASTRO and LEPE (1963) were 1 6 ~ and in ASENJO et al. (1951) 327o. In our cases there was only one case with two nodes in the cerebellum.
236 D i a g n o s i s c a n o n l y be c o n f i r m e d h i s t o l o g i c a l l y .
A p p e a r a n c e d u r i n g the o p e r a t i o n
c o u l d be like a low g r a d e a s t r o c y t o m a , m e t a s t a t i c t u m o u r , a n d also in cases o f d u r a l a d h e s i o n s , t h e r e is a r e s e m b l a n c e to m e n i n g i o m a s . r e d u c e d the m o r t a l i t y rate f r o m 5 0 ~
Treatment with streptomycine
(OBRADORet al., 1973) to 1 0 - 2 0 ~ .
One of our
p a t i e n t s d i e d o f status e p i l e p t i c u s a n d the o t h e r o f p o s t - o p e r a t i c e i n f e c t i o n .
Strep-
t o m y c i n e , P A S a n d I N A H w e r e used as t u b e r c u l o s t a t i c s in o u r cases. S t r e p t o m y c i n e was a d m i n i s t e r e d as l gr per day, t o t a l l y 30 gr, P A S 10-20 gr per d a y a n d I N A H 5-10 m g / k g d u r i n g six to n i n e m o n t h s .
REFERENCES ANDERSON,J. M. and MACMILLAN,J. J.," Intracranial tuberculoma- an increasing problem in Britain. J. Neurol. Neurosurg. Psychiatr. 38: 194, 1975. ARSENI, C . : Two hundred and one cases of intracranial tuberculoma, treated surgically. J. Neurol. Neurosurg. Psychiatr. 21: 308, 1958. ASENJO, A., VALLADARES,H . , and FIERRO,J.: Tuberculomas at the brain. Archives of Neurology and Psychiatry (Chic), 65: 146, 1951. CASTRO,M., and LEPE, A.: Cerebral tuberculoma. Acta Radiologica. Diagnosis 1,821, 1963. DASTUR, H. M., and DESAI,A. D. : A comperative study of brain tuberculomas and gliomas. Brain, 88: 375, 1965. DESCUNS, V., GARRI~,H., PHf:LINE, C.; Tuberculoma of the brain and cerebellum. J. Neurosurg. 2: 243, 1954. GARLANDand ARMITAGE1933: cited by Thrush and Barwick. MERRtTT, H. : A textbook of Neurology, 293, 5th ed. Lea-Febiger, Philadelphia, 1973. NORTHFIELD, D. W. C.." The surgery of the central nervous system, pp. 884, Black Well. Scientific publication, 1973. OBRADOR,S." Neurological Surgery, Vol. 3 1569, 1st ed. W. B. Saunders Company, Philadelphia, 1973. RAMAMURTH1,B. and VARADARAJAN,M. G." Diagnosis of Tuberculomas of the Brain. Clinical and Radiological Correlation. J. Neurosurg. 18: 1-7, 1961. STARR, cited by Thrush and Barwick THRUSH, D. C., and BARWlCK, D D." Three patients with intracranial tuberculomas with unusual features. J. Neurol. Neurosurg. Psychiatr. 37: 566, 1974.