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LETTER TO EDITOR
Year : 2009  |  Volume : 57  |  Issue : 2  |  Page : 218-220

Giant extra-axial posterior fossa tuberculoma in a three-year-old child


Neurosurgery Unit, Department of General Surgery, NSCB Government Medical College and Hospital, Jabalpur, Madhya Pradesh, India

Date of Acceptance31-Mar-2009

Correspondence Address:
Vijay Parihar
Neurosurgery Unit, Department of General Surgery, NSCB Government Medical College and Hospital, Jabalpur, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.51304

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How to cite this article:
Parihar V, Yadav Y R, Sharma D. Giant extra-axial posterior fossa tuberculoma in a three-year-old child. Neurol India 2009;57:218-20

How to cite this URL:
Parihar V, Yadav Y R, Sharma D. Giant extra-axial posterior fossa tuberculoma in a three-year-old child. Neurol India [serial online] 2009 [cited 2019 Aug 21];57:218-20. Available from: http://www.neurologyindia.com/text.asp?2009/57/2/218/51304


Sir,

Intracranial tuberculosis, meningitis, and parenchymal tuberculomas, are still prevalent in some parts of the developing world. Of the intracranial tuberculomas, extra-axial tuberculomas are rare and may present with diagnostic dilemmas. [1]

A three-year-old girl presented with progressive enlargement of head, difficulty in walking and sitting, and progressive stiffness of all the four limbs since one year. There was no history of headache, vomiting, or fever. Developmental history suggested delay in acquiring milestones. On examination, there was macrocephaly, bulging anterior fontanelle, up gaze palsy, and increased tone in all the four limbs. Routine blood tests and chest X-ray were normal. Contrast computed tomography (CT) brain showed [Figure 1] a large ring enhancing (51 51 60 mm) lesion in the left posterior fossa compressing and shifting the fourth ventricle to right side causing obstructive hydrocephalous. There was extension of the lesion to supratentorial compartment through tentorial hiatus. A right ventriculoperitoneal shunt was done followed by definitive surgery. Midline suboccipital craniectomy and durotomy was done. At operation there was a large extra-axial lesion attached to tentorium superiorly and to brainstem medially compressing the cerebellum laterally. There was extension of the lesion to supratentorial compartment through tentorial hiatus. The tumor was yellowish, firm, and relatively avascular. Total excision of the lesion was done [Figure 2]. Histopatholgy was tuberculoma [Figure 3]. The patient improved postoperatively and was discharged on antituberculous treatment. At one-year follow up the patient is asymptomatic.

In developing countries, tuberculomas still account for about one-third of brain masses. [2] Of the intracranial tuberculomas, extra-axial tuberculomas are extremely uncommon. [1],[3] Tuberculoma usually results from the hematogenous seeding of the tubercle bacilli to the leptomeninges and brain parenchyma, resulting in the formation of tubercles. The leptomeningeal tubercles may rupture into the subarachnoid space resulting in meningitis or may remain confined to the meninges forming a hard fibrous mass attached to the dura which may present as tuberculoma-en-plaque, [4],[5] or extra-axial mass like meningioma. [3],[6]

Extra-axial tuberculomas can present with the clinical picture like any other mass lesion, hence, preoperative differential diagnosis from other mass lesions is difficult. The differential diagnosis includes meningioma, lymphoma, metastatic tumor, and sarcoidosis. [4] Findings of systemic infection and many of the usual laboratory correlates of infection may be absent. Cerebrospinal fluid examination may not be informative.[6]

CT and magnetic resonance (MR) imaging features are highly sensitive for tuberculoma, but their specificity for a definite diagnosis is low. Tuberculoma may be seen as a hypo or hyperdense, round or multilobar lesion on CT, and shows homogeneous or ring enhancement. [7] The MRI signal characteristics of intracranial tuberculoma are extremely diverse. An isointense or hypointense core with a hyperintense rim on T2-weighted and FLAIR images is the most common presentation. Core hypointensity of lesion is related to necrosis and the large number of cells. [7] MR spectroscopy may be complementary in the diagnosis and show elevated lipid peak, cholesterol ester, plasmalogen, and phenolic glycolipids. [1] This finding may also help to differentiate tuberculomas from other disease conditions such as malignant tumors as well as the common extra-axial tumor like meningiomas. [7] Large lesion with mass effect was the indication for surgery in this patient. Surgical excision not only helped to establish the histological diagnosis but also helped to resolve the compressive symptoms.

 
  References Top

1.Khanna PC, Godinho S, Patkar DP, Pungavkar SA, Lawande MA. MR spectroscopy-aided differentiation: "Giant" extra-axial tuberculoma masquerading as meningioma. AJNR Am J Neuroradiol 2006;27:1438-40.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Desai K, Nadkarni T, Bhatjiwale M, Goel A. Intraventricular tuberculoma: Case report. Neurol Med Chir (Tokyo) 2002;42:501-3.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Shindo A, Honda C, Baba Y. A case of an intracranial tuberculoma, mimicking meningioma that developed during treatment with anti-tuberculous agents. No Shinkei Geka 1999;27:837-41.  Back to cited text no. 3  [PUBMED]  
4.Dubey S, Devi BI, Jawalkar VK, Bhat DI. Tuberculoma en plaque: A case report. Neurology India 2002;50:497-9.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Bauer J, Johnson RF, Levy JM, Pojman DV, Ruge JR. Tuberculoma presenting as an en plaque meningioma. Case report. J Neurosurg 1996;85:685-8.  Back to cited text no. 5    
6.Lindner A, Schneider C, Hofmann E, Soerensen N, Toyka KV. Isolated meningeal tuberculoma mimicking meningioma: Case report. Surg Neurol 1995;43:81-4.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Wasay M, Kheleani BA, Moolani MK, Zaheer J, Pui M, Hasan S, et al. Brain CT and MRI findings in 100 consecutive patients with intracranial tuberculoma. J Neuroimaging 2003;13:240-7.  Back to cited text no. 7  [PUBMED]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]

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