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| Year : 1999 | Volume
: 47
| Issue : 3 | Page : 238-40 |
Tuberculoma in the Meckel's cave : a case report.
Goel A, Nadkarni T, Desai AP
Department of Neurosurgery, King Edward Memorial Hospital, Parel, Mumbai, 400012, India.
Correspondence Address:
Department of Neurosurgery, King Edward Memorial Hospital, Parel, Mumbai, 400012, India.
A case of an intracranial tuberculoma located within the confines of the Meckel's cave is presented. The patient was young, non-immunocompromised and otherwise in good health. The granuloma mingled with the fibres of the trigeminal nerve. The lesion mimicked a trigeminal neurinoma in its clinical presentation, preoperative investigations and intraoperative consistency and vascularity. The rarity of the location and possible mode of transmission of infection to this site is discussed. The literature on this subject is briefly reviewed.
How to cite this article:
Goel A, Nadkarni T, Desai A P. Tuberculoma in the Meckel's cave : a case report. Neurol India 1999;47:238 |
Tuberculoma or any form of tuberculous infection of the cavernous sinus has only rarely been reported in the literature.[1],[2] The tuberculoma in the presented case was located entirely within the dural walls of the Meckel's cave. Our literature search failed to yield a report of a tuberculous granuloma in this location. The aetiology, presentation and treatment strategy of this lesion is discussed.
A 35 year old housewife presented with complaint of left hemicranial headache for one and half years. For six months, she had tingling and numbness over the left half of the face and diplopia an looking to the left. On examination there was 50% reduction in the proprioceptive sensations in the entire distribution of the left fifth cranial nerve. The corneal sensations were marginally depressed. The temporalis and masseter muscles were wasted. There was left sixth nerve paresis. Rest of the neurological examination was normal. There was no clinical or serological evidence of immuno-deficiency. There was no evidence of tuberculosis elsewhere in her body. Magnetic resonance imaging (MRI) showed an uniformly enhancing tumour in the region of the petrous apex and posterior cavernous sinus [Figure 1a] [Figure 1b]. The cavernous segment of the internal carotid artery, in relation to the tumour, was displaced medially and suggested a lateral and posterior location of the tumour in relation to the cavernous sinus. The tumour was resected completely via a left subtemporal approach.[3],[4] It was entirely within the Meckel's cave. The tumour adjoining dura and the bone were normal. It was grayish white, moderately firm, fleshy and hypovascular tumour resembling a neurinoma. The trigeminal nerve fibres merged inseparably with the tumour. The lesion could be excised by working within the dural sleeves of the fifth nerve. Some of the fibres of the second and third division of the fifth nerve had to be sacrificed to achieve resection. Lumbar drainage of cerebrospinal fluid (CSF) was carried out to assist relaxation of the brain during the surgery. Examination of the CSF showed no abnormality. The patient made an uneventful recovery. Histological examination of specimen revealed typical features of a tuberculoma. There were areas of caseous necrosis surrounded by epitheloid cells, Langhan's giant cells, lymphocytes and plasma cells [Figure 2]. Special stains for organisms were negative. MRI confirmed complete resection of the tumour [Figure 3]. The patient was placed on antituberculous therapy. At six months follow-up, the sensations over her face had significantly improved. Left sixth nerve function had returned to normal. At eighteen month follow-up she was asymptomatic and neurologically normal. MRI repeated at this time showed no abnormality in the brain or in the Meckel's cave.
Tuberculous infections of the brain are still frequent in India and in other developing countries. An increasing number of intracranial tuberculous infection are coming to light round the world due to an increase in the number of acquired immuno deficiency syndrome (AIDS) patients. Improved radiological techniques and awareness of the anatomy and surgery of the region of the cavernous sinus has significantly affected the detection rate of the pathology involving this area. The two dural layers of the Meckel's cave which enclose the Gasserian ganglion and its three divisions (after the fifth nerve enters the Meckel's cave) are free and easily dissectible from it, till the ganglion divides into the three divisions. A sheet of arachnoid and a significant volume of cerebrospinal fluid also surrounds the ganglion. After the Gasserian ganglion divides, the accompanying arachnoid layer becomes thinned out, and the dura is relatively firmly fixed to the divisions of the nerves and continues as their epineurium. The superior third of the Gasserian ganglion and its ophthalmic division and frequently the superior portion of the maxillary division are located in the lateral dural wall of the cavernous sinus.[5] The ophthalmic division is the longest segment of the fifth cranial nerve in direct relation with the cavernous sinus. Despite its relationship to the cavernous sinus, due to the presence of dural and arachnoid sheath, the Gasserian ganglion and its divisions do not come in direct contact with the venous blood of the cavernous sinus. The sphenoid air sinus forms medial relationship with a large part of the Meckel's cave. The exact route of spread of tuberculous infection to within the Meckel's cave remains unclear. Intracranial tuberculosis occurs more frequently in the form of tuberculous meningitis or parenchymal granulomas. There was no evidence of tuberculosis anywhere in the brain or body in our patient. The patient was young and there was no clinical evidence of immunocompromise. Sphenoid and other paranasal sinuses showed no evidence of infection. Transdural spread of tuberculous infection from the cavernous sinus or the sphenoid sinus into the Meckel's cave or into the intracranial compartment has never been reported. We have reported two cases of aspergillus fungal infection involving the paracavernous sinus region. In one of these cases the infection was limited to the Gasserian ganglion and was confined within the dural sheaths of the Meckel's cave.[6] In this case also the exact mode of involvement of Gasserian ganglion could not be elicited. Although, not reported earlier, retrograde spread of dormant infection along the divisions of the fifth nerve into the Gasserian ganglion could be possible. Extradural tuberculomas although rare, have been reported.[7],[8] Two cases of tuberculomas of the cavernous sinus presenting with facial pain and ophthalmoplegia and proven by biopsy have been previously recorded.[1],[2] In both these cases the exact relationship of the lesion to the dural walls of cavernous sinus was not clearly shown. However, from the description it appears that in both these cases, the lesion was actually within the venous spaces of cavernous sinus. Due to the extreme rarity, preoperative presumption of the possibility of tuberculous infection of the Meckel's cave or of the cavernous sinus is difficult. In the presented case, the characteristic features of a tuberculoma were not present even on gross inspection of the lesion. The efficacy of anti-tuberculous drug therapy in dealing with such lesions hidden in a `cave' remains to be seen. The need for such a therapy after its gross resection could eradicate any dormant, remote or neighbouring tuberculosis. Radical extirpation of the lesion followed by chemotherapy were successful in the present case.
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| 2. | Phookan G, Towns GM : Tuberculoma of the cavernous sinus - A case report. Br J Neurosurg 1995; 9 : 205-207. |
| 3. | Goel A : Infratemporal fossa interdural approach for trigminal neurinoma. Acta Neurochir (Wien), 1995; 136 : 99-102. |
| 4. | Goel A : The extradural approach to lesions involving cavernous sinus. Br J Neurosurg 1997; 11 : 134-138. |
| 5. | Goel A, Kothari M, Kobayashi S : Cavernous sinus : A philosophy and anatomy. In : Neurosurgery of complex tumours and vascular lesions Kobayashi S, Goel A, Hongo K, Churchill Livingstone, New York, 1997; 147-162. |
| 6. | Goel A, Nadkarni T, Desai AP : Aspergilloma in the paracavernous sinus region - Two case reports. Neurol Med Chir 1996; 36 : 733-736. |
| 7. | Sinh G, Pandya SK, Dastur DK : The pathogenesis of unusual intracranial tuberculomas and tuberculous space - occupying lesions. J Neurosurg 1968; 9 : 149-159. |
| 8. | Tandon PN : Nervous system tuberculomas and their surgical management. Neurological Infections and Epidemiology 1996; 1 : 109-117. |
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