Unusual Manifestation of Cerebral Infarctions in Tuberculous Meningitis: A Biopsy-Proven Case Report (P1.307)

Background: Cerebral infarction associated with vasculitis is a well-recognized complication of tuberculous meningitis (TBM). Although brain magnetic resonance imaging (MRI) demonstrates the identification of tuberculous vasculitis in most cases, there is little convincing evidence for a causal relation between a specific vessel lesion and cerebral infarction. We experienced a biopsy proven case of unusual manifestation of cerebral infarctions caused by TBM. Case: A 77-year-old female patient, who has been on antituberculosis agents since 8 months ago under the impression of TBM, was presented by sudden left hemiparesis due to right acute posterior internal capsule infarction. Brain MRI and contrast enhanced magnetic resonance angiography (CE MRA) showed 1.2 cm sized enhancing nodule at left sylvian cistern with compression of left middle cerebral artery (MCA) wheareas normal right MCA flow. Fourty days later new right basal ganglia and left cerebral white matter infarct lesions were occurred. Vessel wall brain MRI CE revealed no change of enhancing mass-like lesion around left MCA M2-3 junction and new segmental wall thickening and diffuse enhancement in bilateral MCAs, posterior cerebral arteries and basilar artery, which were suggestive of cerebral vasculitis. Biopsy of enhancing nodule at left sylvian cistern revealed central necrosis surrounded by epithelioid histiocytes and lymphocyte, and these findings were compatible with tuberculous granuloma. Treatment with intravenous dexamethasone in combination with four-drug antituberculous medications were commenced. Conclusion: Vessel wall MRI-detected abnormalities suggestive of vasculitis induce usually infarction in TBM, however, a case of cerebral infarct lesions caused by direct vessel compression of tuberculoma is not reported until now. We presented the unusual manifestation of cerebral infarctions in TBM associated with vasculitis and direct vessel compression of granuloma, which was proven by biopsy.