Clinical and laboratory characteristics of cerebral infarction in tuberculous meningitis: A comparative study

doi:10.1016/j.jocn.2006.07.014

Journal of Clinical Neuroscience

Volume 14, Issue 11, November 2007, Pages 1073-1077

https://doi.org/10.1016/j.jocn.2006.07.014 Get rights and content

Abstract

Cerebral infarction as a complication of tubercular (TB) meningitis is not uncommon, but an adequate comparison of patients with and without stroke has not been carried out. This study was performed to evaluate the clinical characteristics of cerebral infarction secondary to TB meningitis, and to investigate predictive factors for cerebral infarction in patients with TB meningitis. Patients with TB meningitis were recruited over a period of 56 months. They were divided into two groups, those with and those without stroke. Demographic features and clinical, laboratory, and neuroradiological findings were compared between the two groups. We classified strokes into subtypes using neuroimaging findings. Of the 38 patients who were diagnosed with TB meningitis, eight also experienced cerebral infarction. The percentage of cerebrospinal fluid leukocytes that were neutrophils was significantly higher in patients with stroke (68%) than in patients without stroke (31%; p = 0.0001). Upon initial CT imaging, meningeal enhancement was found in 11 patients, and of these patients, six experienced stroke. There were no significant differences between the groups with respect to other clinical and laboratory features, including demographic features, time between meningitis onset and treatment initiation, peripheral white blood cell count, and cerebrospinal fluid findings. Five of the eight patients who developed stroke had lacunar infarcts. One of the three patients with territorial nonlacunar infarction died due to herniation. When treating patients with TB meningitis, the possibility of cerebral infarction should be considered when patients develop focal neurological signs, meningeal enhancement on a CT scan, and sustained polymorphic cerebrospinal fluid pleocytosis.

Introduction

Tuberculous (TB) meningitis remains a challenging illness for clinicians because of the difficulties involved in diagnosis and its high morbidity and mortality.[1], [2] Previous studies have shown an association between poor outcome and an advanced stage of TB meningitis at presentation,³ and have emphasized the importance of prompt diagnosis and early treatment with anti-TB drugs.[4], [5] Intercurrent infection, trauma, immunological disorders, and socioeconomic deprivation are recognized as contributing factors.[1], [2], [6] Much data relating to the complications of TB meningitis, including tuberculoma, hydrocephalus, encephalomyelopathy, radiculomyelitis, and cranial nerve palsies have been reported.[1], [2], [6], [7], [8], [9] Cerebral infarction secondary to infection has also been reported as a complication of TB meningitis. Prevention or reduction of complications, particularly significant complications such as cerebral infarction, is the most challenging goal for providing quality patient care. However, little information concerning the clinical characteristics of patients with cerebral infarction secondary to TB meningitis has been collected. Although some information from case reports and small studies has been published, it is mostly related to radiological findings.

We designed the present study to evaluate the clinical characteristics of patients with cerebral infarction secondary to TB meningitis and to investigate predictive factors for cerebral infarction in patients with TB meningitis. We prospectively analyzed clinical data from patients diagnosed with TB meningitis, and compared the features of patients with and without cerebral infarction.

Section snippets

Patient selection

Between May 2001 and December 2005, we prospectively collected data from all patients with TB meningitis at a university-affiliated teaching hospital. All patients provided informed consent for the study. At the time of admission, we performed cerebrospinal fluid (CSF) analysis. Urgent brain CT scans were completed before the first lumbar puncture, and urgent brain CT or MRI studies were repeated when neurological deterioration occurred or new neurological features were noted. We graded the

Results

A total of 43 patients were diagnosed with TB meningitis in accordance with the diagnostic criteria, but five patients were excluded because of pre-existing stroke risk factors. Ultimately, 38 patients (17 men and 21 women; mean age 34 years; range 16–77 years) were enrolled in this study. Of the 38 patients, eight (21%; five men and three women) developed cerebral infarction during the first week of admission. The mean ages of patients with stroke and patients without stroke were 36.5 years

Discussion

In 1947, Smith and Daniel reported an 11-year-old boy who was found at autopsy to have cerebral infarction as a complication of TB meningitis,¹⁴ and since then there have been many reports of vascular lesions in patients with TB meningitis.[2], [15] The incidence of cerebral infarction secondary to TB meningitis is reportedly 6–47%.[16], [17] This is not uncommon, and in the present study we found that 21% of TB meningitis patients developed stroke, which falls within the previously reported

Acknowledgement

We thank Dr. Yasushi Miyoshi at the Asagi Hospital, Fukuoka, Japan, for his valuable comments.

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Cited by (50)

Relationship between neutrophil count in cerebrospinal fluid and cerebral infarct appearance in head MRI on tuberculous meningitis patients
2023, European Journal of Radiology Open
Citation Excerpt :
Moreover, Diffusion-Weighted Image (DWI) may also be used in order to determine the cerebral infarction in TBM. The MRI has a higher sensitivity than CT scan in detecting cerebral infarction [11,12]. However, the MRI features for cerebral infarction in TBM vary over different stage.
To determine the relationship between neutrophils count in cerebrospinal fluid and cerebral infarction in head magnetic resonance imaging (MRI) on patients with tuberculous meningitis
A diagnostic study was done on patients with tuberculous meningitis (TBM) who underwent head MRI examination and cerebrospinal fluid analysis at Dr. Hasan Sadikin General Hospital from January 2015 to September 2016. TBM was diagnosed by Mycobacterium tuberculosis isolation from cerebrospinal fluid. Cut-off value of neutrophil count was determined using receiver operating characteristics (ROC) curve. Conformity test was done using Kappa test.
Thirty seven subjects were recruited in this study. Higher neutrophil count in CSF was observed on subjects with cerebral infarction (p < 0.05). Cut-off value of neutrophil count in CSF was determined as > 41 %. There was a moderate conformity between higher neutrophil count in CSF and cerebral infarction appearance in MRI (p < 0.05, Kappa score 0.529).
Higher neutrophil count was associated with the appearance of cerebral infarct in head MRI on adult patients with tuberculous meningitis.
Predictors of Infarction in Tuberculous Meningitis in Indian Patients
2021, Journal of Stroke and Cerebrovascular Diseases
Stroke is a devastating complication of tuberculous meningitis (TBM) and is an important determinant of its outcome. We propose a model which would help to predict development of infarction or cerebrovascular events in patients of TBM.
A prospective study with n=129 patients of TBM were evaluated for predictors and outcomes of stroke. A diagnostic grid was formulated with clinical, laboratory and radiology as parameters to predict the vascular outcomes. All patients were followed up for mortality and disability on the basis of modified rankin score (mRS). MRI & CSF cytokines TNF–alpha, IFN- gamma & IL-6,8, 10 were measured at baseline and 3 months. The diagnosis of TBM included definite, probable & possible types and stage I & II with early and late onset of symptoms respectively.
The mortality was 16.2% and 19.4% of all patients developed stroke. The mean GCS, barthel index and mRS at admission was 57.03± 9.5,10.2±2.3 & 3.3±0.03 respectively mild to moderate infection and functional limitation. Barthel index (BI) happened to be a strong predictor [F=32.6, p=0.001, t=15.5, βeta coefficient =0.002] followed by biomarker TNF-α [F=18.9, p=0.02, t= -2.07, βeta coefficient=-0.04]. N=25 patients developed stroke with TNF-α, IL-6, IFN -γ showing statistically significant increase in all the stroke affected TBM (95% CI; 4.5 to 1.2; p=0.003). At 3 months, it was observed that mRS was statistically significant between stage I & II (95% CI; 5.4 to 2.1; p=0.04).
Our data revealed that 19.4% patients developed vascular events during the hospital stay or follow up. We recruited late onset TBM as compared to early onset. BI, TNF-α, IL6 are most potent predictors of stroke post TBM.
Cerebral infarction and tuberculosis: case report and literature review
2020, Revue de Medecine Interne
La tuberculose neuroméningée est une forme rare de tuberculose, mais reste une des présentations de plus mauvais pronostic. La survenue d'infarctus cérébraux dans ce contexte est un facteur aggravant.
Un homme asiatique de 48 ans se présentait aux urgences pour une dysarthrie accompagnée de troubles de la déglutition, d'installation rapidement progressive. Le scanner cérébral objectivait une lacune ischémique récente de la capsule interne droite. La ponction lombaire montrait une méningite à liquide clair hypoglycorachique. Des images thoraciques micronodulaires faisaient évoquer le diagnostic de tuberculose, qui était confirmé par le lavage broncho-alvéolaire. Une quadrithérapie antituberculeuse et une corticothérapie permettaient d'obtenir une amélioration clinique en quelques semaines.
Les infarctus cérébraux lors des tuberculoses neuroméningées sont des événements dont il ne faut sous-estimer ni la fréquence ni la gravité. Leur mauvais pronostic est dû en partie à une prise en charge mal définie, qui associe traitement antituberculeux et corticothérapie précoce.
Although tuberculous meningitis is an uncommon presentation of tuberculosis, it still remains one of the deadliest forms of this disease. In this context, the occurrence of a cerebral infarct is an aggravating factor.
A 48-year-old Asian man presented himself in the emergency room for dysarthria and dysphagia of progressive onset. Cerebral CT showed a recent ischemic defect of the right internal capsule. Lumbar puncture showed meningitis with low sugar levels. Pulmonary micronodules on the thoracic CT suggested tuberculosis, which was confirmed by a broncho-alveolar lavage. Anti-tuberculosis treatment and early corticosteroid resulted in an improvement of the patient's state.
Cerebral infarctions in patients with tuberculous meningitis are events that cannot be underestimated in terms of frequency or severity. Their poor prognosis is partly the result of insufficiently defined management, which combines anti-tuberculosis treatment and early corticosteroid therapy.
Neurological complications after tuberculous meningitis in a multi-state cohort in the United States
2017, Journal of the Neurological Sciences
Citation Excerpt :
Furthermore, complication rates differ depending on access to medical resources including antimicrobial therapy and advanced diagnostic techniques. The rate of stroke after TBM varies between 15 and 57% [9,10,12–24], with lower numbers reported in studies where stroke was identified clinically or by CT [15,17] and higher numbers in studies in which serial MRIs [10,14,16,21,22] or autopsies were performed [12,13]. The previously documented high rates of neurological complications may also reflect the fact that the majority of prior studies were performed in endemic areas, which are typically resource-limited countries with major gaps in healthcare infrastructure; however, in this study more than half of TBM patients died or had a neurological complication even in the United States, a country with general availability of critical care units, specialized healthcare providers including neurosurgeons, advanced neuroimaging, modern laboratory techniques to identify TBM, access to antimicrobial therapy, and rehabilitation centers.
To assess the rate of neurological complications and mortality after tuberculous meningitis in the United States.
The authors performed a retrospective cohort study of all patients 18 years or older hospitalized for tuberculous meningitis in California between 2005 and 2010, New York between 2006 and 2012, and Florida between 2005 and 2012. Outcomes of interest were mortality and the following neurological complications: stroke, seizure, hydrocephalus requiring a ventriculoperitoneal shunt, vision impairment, and hearing impairment. Kaplan–Meier survival statistics were used to assess the cumulative rate of neurological complications and death. Cox proportional hazards regression was used to compare rates of complications in patients with and without human immunodeficiency virus (HIV) after adjustment for comorbidities.
806 patients with tuberculous meningitis were identified, among whom the cumulative rate of any complication or death was 55.4% (95% CI, 51.5–59.3%). More than two-thirds of complications occurred during the initial hospitalization for tuberculous meningitis. Individual neurological complications were not uncommon: the cumulative rate of stroke was 16.8% (95% CI, 14.0–20.0%), the rate of seizure was 18.8% (95% CI, 15.4–22.8%), and the rate of ventriculoperitoneal shunting was 8.4% (95% CI, 6.4–10.9%). Vision impairment occurred in 21.6% (95% CI, 18.5–25.1%) of patients and hearing impairment occurred in 6.8% (95% CI, 4.9–9.4%). The mortality rate was 21.5% (95% CI, 18.4–24.9%). Patients with HIV infection were not at increased risk of complications compared to patients without HIV (hazard ratio, 1.2; 95% CI, 0.9–1.6).
Tuberculous meningitis is associated with significant risk of neurological complications and death in the United States.
Risk assessment of the outcome for cerebral infarction in tuberculous meningitis
2014, Revue Neurologique
Citation Excerpt :
Infarct is a poor prognostic predictor in children with TBM [13]. Although many studies have evaluated CI in TBM [10,12,14–17], most have been radiological studies, and only a few have focused on the correlations between CI and clinical factors in TBM patients [6,11,17]. No comprehensive study has conducted a risk assessment for CI in patients with TBM [10,12,17].
Cerebral infarction in tuberculous meningitis is a major risk factor for permanent disability. This study assessed the clinical presentation of tuberculous meningitis and risks factors for cerebral infarction.
Thirty-eight adult patients with tuberculous meningitis were studied between 2002 and 2006. Clinical, radiological, and laboratory data of patients with cerebral infarction were compared with those of patients without cerebral infarction. Patients with cerebral infarction were significantly older (65.1 vs 52.1 years), had higher risk assessment scores (3.7 vs 2.2), and more often had basal meningeal enhancement on imaging (92.3% vs 60.0%), mild to moderate sequelae (69.2% vs 4%), an overall poor brain outcome (69.2% vs 8%), aspirin prescription (84% vs 8%), and neurosurgical intervention for hydrocephalus (54.0% vs 16.0%). Cerebral infarction patients were also more likely to have experienced doctor-related delays in antituberculosis (61.5% vs 36%) and corticosteroid (61.5% vs 32%) therapy.
The Framingham risk score would be an option for tuberculous meningitis patients to access cerebral infarction risk. Contrast-enhanced brain imaging is helpful for exploring basal meningeal enhancement, in order to obtain an early diagnosis. Antituberculosis, corticosteroid, and aspirin therapies should be started immediately when tuberculous meningitis is suspected.
L’infarctus cérébral dans la méningite tuberculeuse est un facteur de risque majeur d’incapacité permanente. Cette étude a évalué la présentation clinique de la méningite tuberculeuse et les facteurs de risque d’infarctus cérébral.
Les cas de trente-huit patients adultes atteints de méningite tuberculeuse ont été étudiés entre 2002 et 2006. Les données de laboratoire et celles cliniques et radiologiques des patients avec un infarctus cérébral ont été comparées à celles des patients sans infarctus cérébral. Les patients avec un infarctus cérébral étaient significativement plus âgés (65,1 contre 52,1 années), avaient des scores plus élevés dans l’évaluation des risques (3,7 vs 2,2), avaient le plus souvent vu une amélioration méningée fondamentale sur l’imagerie (92,3 % vs 60,0 %), des séquelles de légères à modérées (69,2 % contre 4 %), un résultat global médiocre du cerveau (69,2 % contre 8 %), une prescription d’aspirine (84 % contre 8 %) et une intervention neurochirurgicale pour hydrocéphalie (54,0 % contre 16,0 %). Les patients ayant subi un infarctus cérébral étaient également plus susceptibles de profiter en retard d’une thérapie antituberculeuse (61,5 % contre 36 %) et corticostéroïde (61,5 % contre 32 %) décidée par des médecins expérimentés.
Le score de risque de Framingham serait une option pour les patients atteints de méningite tuberculeuse pour accéder au risque d’infarctus cérébral. Le renforcement du contraste en imagerie cérébrale est utile pour explorer l’amélioration méningée fondamentale et ce, afin d’obtenir un diagnostic précoce. Des thérapies antituberculeuses, à base de corticoïdes ou d’aspirine, doivent être lancées dès qu’une méningite tuberculeuse est suspectée.
Meningovascular tuberculosis: Case study of an atypical presentation
2014, Neurologia

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Clinical StudyClinical and laboratory characteristics of cerebral infarction in tuberculous meningitis: A comparative study

Abstract

Introduction

Section snippets

Patient selection

Results

Discussion

Acknowledgement

Infect Dis Clin North Am

J Pediatr

Surg Neurol

Tuber Lung Dis

Tubercle

Radiol Clin North Am

Tuberculous meningitis

JAMA

Tuberculous meningitis: a 30-year review

Clin Infect Dis

Tuberculous meningitis in adults: an eleven-year review

Int J Tuberc Lung Dis

Tuberculous meningitis in children: a retrospective study of 79 patients, with an analysis of prognostic factors

Can Med Assoc J

Tuberculous meningitis

Polyradiculomyelitis associated with clinically diagnosed tuberculous meningitis

Eur Neurol

Clinical relevance of hydrocephalus as a presenting feature of tuberculous meningitis

QJM

Interobserver agreement for the assessment of handicap in stroke patients

Stroke

Tuberculous meningitis

J Neurol Neurosurg Psychiatry

Tuberculous meningitis in patients infected with the human immunodeficiency virus

N Engl J Med

Bacterial meningitis: A review of selected aspects

N Engl J Med

Clinical Study
Clinical and laboratory characteristics of cerebral infarction in tuberculous meningitis: A comparative study