Clinical and Radiological End Points to Stop Anti-Tubercular Treatment in Central Nervous System Tuberculoma and Predictors of Poor Outcome: A Retrospective Study

Ankit Gupta Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India;

Search for other papers by Ankit Gupta in
Current site
Google Scholar
PubMed
Close
,
Vimal Kumar Paliwal Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India;

Search for other papers by Vimal Kumar Paliwal in
Current site
Google Scholar
PubMed
Close
,
Swati Bharatveer Department of Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India;

Search for other papers by Swati Bharatveer in
Current site
Google Scholar
PubMed
Close
,
Prabhakar Mishra Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India;

Search for other papers by Prabhakar Mishra in
Current site
Google Scholar
PubMed
Close
, and
Neeraj Jain Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Search for other papers by Neeraj Jain in
Current site
Google Scholar
PubMed
Close
Restricted access

ABSTRACT.

The clinical and radiological end points to stop anti-tubercular treatment in central nervous system (CNS) tuberculoma are not known. This retrospective study was done to determine end points to stop anti-tubercular treatment and find the predictors of poor outcome in patients with CNS tuberculoma. Patients who were admitted with a diagnosis of brain/spine tuberculoma between January 2015 and December 2019 and who completed a minimum of 1-year follow-up were enrolled. Clinical and radiological end points to stop anti-tubercular treatment and predictors of death and poor outcome (modified Rankin scale > 2) were analyzed. One hundred and eight patients (male-to-female ratio, 47 [43.5%]:61 [56.5%]; brain tuberculoma, 102; spinal cord tuberculoma, 14; brain and spinal cord tuberculoma, 8) were included in the study. Median duration of anti-tubercular treatment was 24 months. Radiological resolution of tuberculoma (resolution of gadolinium-enhancing lesion, gliosis, calcification, cord atrophy, or syrinx formation) and radiological halt (no increase in size/number of tuberculoma on magnetic resonance imaging scans done 6 months apart) were used as end points to stop anti-tubercular treatment in 69 and 7 patients, respectively. Seven patients stopped their treatment by themselves, and 25 patients died. Altered sensorium, motor weakness, infarcts, hydrocephalus, and constitutional symptoms of tuberculous meningitis were predictors of poor outcome or death in CNS tuberculoma patients. Radiological resolution or radiological halt of brain/spinal cord tuberculoma was a reasonable end point to stop anti-tubercular treatment. However, this may require 24 months or more of anti-tubercular treatment. Associated tuberculous meningitis and its complications portend a poor prognosis.

Author Notes

Authors’ addresses: Ankit Gupta and Vimal Kumar Paliwal, Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, E-mails:drankitgupta90@gmail.com and dr_vimalkpaliwal@rediffmail.com. Swati Bharatveer, Department of Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, E-mail: drswatimamc@gmail.com. Prabhakar Mishra, Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, E-mail: drpmishra@sgpgi.ac.in. Neeraj Jain, Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, E-mail: neerajdmrd@gmail.com.

Address correspondence to Vimal Kumar Paliwal, Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India. E-mails: dr_vimalkpaliwal@rediffmail.com
  • 1.

    World Health Organization , Global Tuberculosis Report 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/336069/9789240013131-eng.pdf. Accessed January 9, 2023.

    • PubMed
    • Export Citation
  • 2.

    Thakur K, Das M, Dooley KE, Gupta A, 2018. The global neurological burden of tuberculosis. Semin Neurol 38: 226237.

  • 3.

    Rich AR, 1933. The pathogenesis of tuberculous meningitis. Bull John Hopkins Hosp 52: 537.

  • 4.

    Be NA, Kim KS, Bishai WR, Jain SK, 2009. Pathogenesis of central nervous system tuberculosis. Curr Mol Med 9: 9499.

  • 5.

    Dastur HM, 1972. A tuberculoma review with some personal experiences. I. Brain. Neurol India 20: 111126.

  • 6.

    Wasay M, Moolani MK, Zaheer J, Khealani BA, Smego RA, Sarwari AR, 2004. Prognostic indicators in patients with intracranial tuberculoma: a review of 102 cases. J Pak Med Assoc 54: 8387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Ministry of Health and Family Welfare, Government of India , 2016. Index-Tb Guidelines: Guidelines for Extrapulmonary Tuberculosis for India. Available at: https://tbcindia.gov.in/WriteReadData/l892s/5585665076Index-TB%20Guidelines.pdf. Accessed January 9, 2023.

    • PubMed
    • Export Citation
  • 8.

    World Health Organization , 2010. Treatment of Tuberculosis: Guidelines. 4th ed. Geneva, Switzerland: World Health Organization. Available at: https://books.google.co.in/books?id=pK0fqlkjFGsC.

    • PubMed
    • Export Citation
  • 9.

    World Health Organization , 2017. Guidelines for Treatment of Drug-Susceptible Tuberculosis and Patient Care: 2017 Update. Geneva, Switzerland: World Health Organization.

    • PubMed
    • Export Citation
  • 10.

    Thwaites GF, 2009. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect 59: 167187.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Khadilkar SV, Kadam ND, Kulkarni RV, Meshram CM, Meshram AR, Patel BA, Chheda AH, 2019. Guidelines versus ground lines: tuberculosis of the central nervous system. Neurol India 67: 787.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Poonnoose SI, Rajshekhar V, 2003. Rate of resolution of histologically verified intracranial tuberculomas. Neurosurgery 53: 873879.

  • 13.

    Prasad K, Sahu JK, 2010. Duration of anti-tubercular treatment in tuberculous meningitis: challenges and opportunity. Neurol India 58: 723726.

  • 14.

    Ahuja GK, Mohan KK, Prasad K, Behari M, 1994. Diagnostic criteria for tuberculous meningitis and their validation. Tuber Lung Dis 75: 149152.

  • 15.

    Nair BR, Rajshekhar V, 2019. Factors predicting the need for prolonged (> 24 months) antituberculous treatment in patients with brain tuberculomas. World Neurosurg 125: e236e247.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Goyal V, Elavarasi A, Abhishek GS, Behari M, 2019. Practice trends in treating central nervous system tuberculosis and outcomes at a tertiary care hospital: a cohort study of 244 cases. Ann Indian Acad Neurol 22: 37.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Ramappa V, Aithal GP, 2013. Hepatotoxicity related to anti-tuberculosis drugs: mechanisms and management. J Clin Exp Hepatol 3: 3749.

  • 18.

    Rajeswari R, Sivasubramanian S, Balambal R, Parthasarathy R, Ranjani R, Santha T, Somasundaram PR, Ganapathy S, Sudarsana K, Sayeed ZA, 1995. A controlled clinical trial of short-course chemotherapy for tuberculoma of the brain. Tuber Lung Dis 76: 311317.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Awada A, Daif AK, Pirani M, Khan MY, Memish Z, Al Rajeh S, 1998. Evolution of brain tuberculomas under standard antituberculous treatment. J Neurol Sci 156: 4752.

  • 20.

    Shah IA, Asimi RP, Kawoos Y, Wani M, Sarmast AH, 2016. Tuberculomas of the brain with and without associated meningitis: a cohort of 28 cases treated with anti-tuberculosis drugs at a tertiary care centre. IntJ Contemp Med Res 3: 34843487.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Mishra R, Shrivastava A, Raj S, Chouksey P, 2021. Intracranial tuberculomas and tubercular abscess –overcoming challenges. Curr Pract Neurosci 69: 114.

  • 22.

    Goyal V, Elavarasi A, Abhishek GS, Behari M, 2019. Practice trends in treating central nervous system tuberculosis and outcomes at a tertiary care hospital: a cohort study of 244 cases. Ann Indian Acad Neurol 22: 37.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Morales H, Alfaro D, Martinot C, Fayed N, Gaskill-Shipley M, 2015. MR spectroscopy of intracranial tuberculomas: a singlet peak at 3.8 ppm as potential marker to differentiate them from malignant tumors. Neuroradiol J 28: 294302.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Arseni C, 1958. Two hundred and one cases of intracranial tuberculoma treated surgically. J Neurol Neurosurg Psychiatry 21: 308.

  • 25.

    Sinha MK, Garg RK, Anuradha HK, Agarwal A, Singh MK, Verma R, Shukla R, 2010. Vision impairment in tuberculous meningitis: predictors and prognosis. J Neurol Sci 290: 2732.

  • 26.

    Aaron S, Mathew V, Anupriya A, Sunithi M, Maya T, Goel M, Alexander M, 2010. Tuberculous optochiasmatic arachnoiditis. Neurol India 58: 732.

  • 27.

    Metcalf T et al., 2018. Evaluation of the GeneXpert MTB/RIF in patients with presumptive tuberculous meningitis. PLoS One 13: e0198695.

  • 28.

    Misra R, Kesarwani V, Nath A, 2021. Assessment of burden of drug-resistant tuberculosis at a tertiary care centre in northern India: a prospective single centre cohort study. BMJ Open 11: e044096.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Dorjee K et al., 2020. High prevalence of rifampin-resistant tuberculosis in mountainous districts of India. Indian J Tuber 67: 5964.

  • 30.

    Bagga A, Kalra V, Ghai OP, 1988. Intracranial tuberculoma: evaluation and treatment. Clin Pediatrics. 27: 487490.

  • 31.

    Garg A, Kaur KP, Devaranjan Sebastian LJ, Gaikwad SB, Bhatia R, Singh MB, Srivastava A, Pandey RM, 2019. Conglomerate ring-enhancing lesions are common in solitary neurocysticercosis and do not always suggest neurotuberculosis. Ann Indian Acad Neurol 22: 6772.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Kaur KP, Garg A, Devaranjan Sebastian LJ, Bhatia R, Singh MB, Srivastava A, Tripathi M, Padma MV, 2021. Recurrent neurocysticercosis: not so rare. Neurol India 69: 385391.

  • 33.

    Gupta MM, Garg A, Kaur K, Joseph L, Goyal V, Srivastava AK, 2021. A neurocysticercosis infestation masquerading as malignant brain tumour. Ann Indian Acad Neurol 24: 970972.

    • PubMed
    • Search Google Scholar
    • Export Citation
Past two years Past Year Past 30 Days
Abstract Views 1939 1939 173
Full Text Views 25 25 10
PDF Downloads 30 30 15
 
Membership Banner
 
 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save