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LETTER TO EDITOR
Year : 2004  |  Volume : 52  |  Issue : 1  |  Page : 129-130

Tuberculous granuloma of the spheno-clival region


Department of Neurosurgery, Kasturba Medical College And Hospital, Manipal

Correspondence Address:
epartment of Neurosurgery, Kasturba Medical College And Hospital, Manipal
shenoysn@yahoo.com



How to cite this article:
Shenoy S N, Raja A. Tuberculous granuloma of the spheno-clival region. Neurol India 2004;52:129-30


How to cite this URL:
Shenoy S N, Raja A. Tuberculous granuloma of the spheno-clival region. Neurol India [serial online] 2004 [cited 2019 Nov 22];52:129-30. Available from: http://www.neurologyindia.com/text.asp?2004/52/1/129/6729


Sir,
The clivus is one of the common sites for diverse pathological lesions.[1] Tuberculosis commonly involves the craniovertebral junction causing atlanto-axial dislocation.[2] However, primary skull base tuberculoma is extremely rare.[3] A case of primary spheno-clival tuberculoma without involvement of the craniovertebral junction is reported and the management is discussed.
A 24-year-old, non-immunocompromised lady presented with history of progressive diplopia and inward deviation of both eyes for one month. Cranial nerve examination revealed paresis of both lateral recti. The rest of the neurological and systemic examination revealed no abnormality.
Her hematological and laboratory examination revealed no abnormality. Chest X-ray was normal. CT scan revealed evidence of an isodense, minimally enhancing, destructive and expansive clival lesion [Figure - 1]. T1-weighted MRI images showed an isointense lesion involving primarily the clivus and sphenoid sinus and extending anteriorly into the nasopharynx. The lesion enhanced on Gadolinium. There was a central zone of necrosis. The craniovertebral junction was normal [Figure - 2].
The patient underwent a trans-ethmoidal decompression of the lesion. The lesion was firm in the periphery and was vascular. However, the central part of the tumor was cheesy and avascular. Histopathological examination of the specimen revealed characteristic features of a tuberculoma with Langerhan's giant cells and epithelioid cells. Acid-fast bacilli could not be isolated. Postoperatively, the patient was treated with antituberculous treatment [ATT]. The patient progressively improved and her abducens nerve function recovered completely. ATT was continued for 18 months. Repeat cranial CT scan showed complete disappearance of the lesion.
Tuberculosis commonly involves the craniovertebral junction causing atlanto-axial dislocation.[2] Tuberculosis involving the clivus and sparing the craniovertebral junction is rare.[1],[3] The mycobacterium usually reaches the bone by hematogenous spread from a focus, usually in the lung.[4],[5] Although the exact mode of transmission of the mycobacterium is unclear, it could have been from the pharyngeal lymphoid tissues. Unlike the characteristic ring enhancement seen in cerebral parenchymal tuberculoma, skull base tuberculoma shows a diffuse enhancement and imaging characters mimic a malignant tumor, making the diagnosis of tuberculosis difficult.[4] Intraoperative frozen section examination can help in determining the surgical strategy. A high degree of clinical suspicion is also mandatory.  

     References Top

1.Sekhar LN, Goel A, Sen CN. Extradural Clival Tumours. In: Apuzzo MLJ, ed. Brain Surgery: complication avoidance and management. New York: Churchill Livingston; 1993. pp. 2221-44.  Back to cited text no. 1    
2.Kanaan IU, Ellis M, Safi T, Al Kawi MZ, Coates R. Craniocervical junction tuberculosis: a rare but dangerous disease. Surg Neurol 1999;51:21-5.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Selvapandian S, Chandy MJ. Tuberculous granuloma of the clivus. Br J Neurosurg 1993;7:581-2.  Back to cited text no. 3  [PUBMED]  
4.Sencer S, Sencer A, Aydin K, Hepgul K, Poyanli A, Minareci O. Imaging in tuberculosis of the skull and skull-base: case report. Neuroradiology 2003;45:160-3.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Gupta PK, Kolluri VR, Chandramouli BA, Venkataramana NK, Das BS. Calvarial tuberculosis: a report of two cases. Neurosurgery 1989;25:830-3.  Back to cited text no. 5    

 

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Online since 20th March '04
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