Acta Neurochir DOI 10.1007/s00701-015-2493-6
LETTER TO THE EDITOR - VASCULAR
Cerebral venous thrombosis associated with tuberculous meningitis: a rare complication of a common disease Raghvendra Ramdasi 1 & Amit Mahore 1 & Juhi Kawale 2 & Smita Thorve 3
Received: 14 April 2015 / Accepted: 23 June 2015 # Springer-Verlag Wien 2015
Dear Sir, A 20-year-old female presented with complaints of high-grade fever, headache, vomiting, and neck stiffness for 4 days. On neurological examination, the patient had neck stiffness with positive Kerning’s sign. The patient was admitted to the medical ward and investigated. Her cerebrospinal fluid (CSF) examination revealed 60 cells/mm 3 (90 % lymphocytes), 310 mg% proteins and 16 mg% glucose (corresponding plasma glucose 140 mg%). Ziehl–Neelsen (ZN) stain and Gram stain were negative. PCR for DNA of Mycobacterium tuberculosis in CSF was positive and adenosine deaminase (ADA) levels were raised. Magnetic resonance imaging (MRI) of brain with contrast revealed leptomeningeal enhancement and basal exudates (Fig. 1a, b). Chest X-ray showed consolidation in the left lung. The patient was started on anti-tubercular treatment and steroids. The patient had significant improvement in her symptoms in 4 days and took discharge against medical advice. After 2 days, she had a single episode of generalized tonic-clonic convulsion, which she ignored. She was brought to our emergency department in an unconscious state 1 day after the epileptic attack. On examination, she had decerebrate posturing on painful stimuli.
* Raghvendra Ramdasi [email protected]
Department of Neurosurgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai 400012, India
Department of Medicine, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, India
Department of Neurosurgery, Jaslok Hospital & Research Centre, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai, Maharashtra 400026, India
Her left pupil was dilated and not reacting to light; whereas the right pupil was normal. Computed tomography (CT) scan of the brain revealed patchy heterogenous hyperdensity in the left temporal region with mass effect (Fig. 1c). MRI of her brain showed a left temporal heterogenous lesion with blooming on gradient echo (GRE) sequence and restriction of diffusion on diffusion imaging (DWI). Magnetic resonance venography (MRV) revealed thrombosis of the left transverse and sigmoid sinus (Fig. 1d). She was taken to emergency surgery and left fronto-temporo-parietal decompressive craniectomy with augmentation duraplasty was performed. She succumbed due to severe chest tuberculosis after initial postoperative neurological improvement. Her post-mortem examination confirmed the presence of a large thrombus in the left transverse and sigmoid sinus. Despite the high prevalence of tuberculosis in tropical countries, its association with cerebral venous thrombosis (CVT) is rarely reported . Only eight cases of tuberculosis causing CVT have been reported in the literature to date, out of which four are from India. Three cases had tuberculous meningitis. Other reported cases had occipital tuberculous abscess, multiple cerebral tuberculomas, and calvarial tuberculosis [1–5]. Endothelial injury due to inflammatory response, increased platelet aggregation, and release of procoagulant factors are the proposed mechanisms of tuberculosis causing thrombosis. Mycobacterium tuberculosis-infected microglia release cytokines like TNF-α and IL-1β, which have an additive effect in procoagulant activity on human endothelial cells and may play an important role in thrombosis . We propose that the small vasculitic infarcts caused by tuberculous meningitis release local tissue factor, which is responsible for increased procoagulant activity in local milieu. Direct compression of the sinus by granulation tissue or abscess constitutes another mechanism of sinus thrombosis [2, 5].
Acta Neurochir Fig. 1 Axial (a) and sagittal (b) post-contrast images of T1weighted magnetic resonance imaging (MRI) showing leptomeningeal enhancement and basal exudates. c Axial image of plain computed tomography (CT) revealing patchy heterogenous hyperdensities in the left temporoparietal region. d Magnetic resonance venography (MRV) showing thrombosis of left transverse and sigmoid sinus
Clinical manifestations of CVT are highly variable, include four syndromes: (a) isolated intracranial hypertension presenting as severe headache; (b) focal neurological deficits like seizures and hemiparesis; (c) encephalopathy causing altered sensorium; and ((d) cavernous sinus syndrome or their combinations. Therefore, severe headache, focal deficits, or altered sensorium in tuberculous meningitis should be taken seriously and promptly investigated. Early antithrombin therapy, measures to decrease raised ICT and timely decompressive craniectomy if required can prevent propagation of thrombus, limit area of infarction, minimize secondary brain injury, and most importantly save life . Tuberculous meningitis is a very rare cause of cerebral venous thrombosis. High index of suspicion is needed for early diagnosis and timely intervention. Conflict of interest None. Patient Consent Obtained.
Verma R, Lalla R, Patil TB, Tiwari N (2013) A rare presentation of cerebral venous sinus thrombosis associated with tubercular meningitis. BMJ Case Rep. doi:10.1136/bcr-2013-009892 Barber PA, Sieradzan KS, Schady W (1999) Superior sagittal sinus obstruction and tuberculous abscess. Acta Neurol Scand 99(3):202–3 Kakkar N, Banerjee AK, Vaisishta RK, Marwaha N, Deodhar SD (2003) Aseptic cerebral venous thrombosis associated with abdominal tuberculosis. Neurol India 51(1):128–9 Messouak O, Amara B, Benjelloun FZ, Tizniti S, Benjelloun MC, Belahsen MF (2007) Aseptic cerebral venous thrombosis and multiple cerebral tuberculomas associated with pulmonary miliary tuberculosis. Rev Neuro(Paris) 163(2):238–40, Article in French Sundaram PK, Sayed F (2007) Superior sagittal sinus thrombosis caused by calvarial tuberculosis: case report. Neurosurgery 60(4), E776 Filippidis A, Kapsalaki E, Patramani G, Fountas KN (2009) Cerebral venous sinus thrombosis: review of the demographics, pathophysiology, current diagnosis, and treatment. Neurosurg Focus 27(5):E3