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190]
Review A r tic le
Abstract
Tuberculoma of the brain is an important clinical entity. The main challenge in the management of brain tuberculoma is its diagnosis.
Appearance in computed tomography (CT) scan of brain is common and consists of solitary or multiple ring‑enhancing lesions
with moderate perilesional edema, but these are not specific for tuberculoma as neurocysticercosis (NCC), coccidiomycosis,
toxoplasmosis, metastasis and few other diseases may also have similar appearance on CT scan brain. Cerebrospinal fluid
examination is often normal and biopsy and tissue culture from the lesion though the diagnosis of choice is technically too
demanding and not feasible in most of the times. All these put the clinicians in a great dilemma as regard to a confidant
diagnosis of tuberculoma of the brain. With advancement of imaging techniques, magnetic resonance imaging (MRI) of brain
with magnetic resonance spectroscopy (MRS) has shown a great hope in this context as MRS shows a specific lipid peak
in cases of tuberculoma which is not seen in any other differential diagnoses of tuberculoma. This review article is written to
have an overview regarding the current diagnostic approach for brain tuberculoma with special emphasis on the role of MRS.
Extensive literature review of the articles published in English was conducted using Google search, Google Scholar, PubMed
and Medline using the keywords such as ring‑enhancing lesions, etiology, tuberculoma, NCC, CT scan brain, MRI, MRS, images.
onset partial seizure, and the two most common etiologies So, although CT scan of brain is primary investigation
are NCC followed by tuberculoma.[8,9] of choice and is very sensitive (100%) in detecting
ring‑enhancing lesions, it lacks specificity and has got a
Neurocysticercosis on the other hand classically presents pretty low negative predictive value (31%).[11,18] This clearly
with multiple, small (<20 mm) lesion with ring‑enhancement, emphasizes the limitation of CT scan of the brain with
presence of eccentric nodules, moderate vasogenic edema contrast as the sole diagnostic modality of intracranial
that usually does not result in midline shift.[4,12,13,16,17] tuberculoma.
Though, lesions with size >20 mm, irregular outline and • Magnetic resonance imaging
midline shift in CT brain has been proposed to favor
a diagnosis of tuberculoma by some authors,[4,17] these Conventional MRI brain is better than CT scan brain
descriptions are not mutually very exclusive or specific for for anatomical delineation, but the findings are not
neither of the two conditions.[5,9] Moreover, pyogenic brain always specific for tuberculoma and are often difficult
abscess, brain tumors (metastasis or primary), lymphoma, to differentiate between tuberculoma and NCC in a
toxoplasmosis and cryptococcosis in immunocompromised conventional MRI. A non caseating tuberculoma is
subjects can also give rise to similar findings on CT scan hyperintense on T2‑weighted and but appears hypointense
of brain [Tables 1 and 2].[4,10,17] on T1‑weighted images. But a caseating tuberculoma is seen
as iso‑to hypointense on both T1‑ and T2‑weighted images,
Table 1: Spectrum of differential diagnoses of with an iso‑to hyperintense rim on T2‑weighted images.
single ring‑enhancing lesion in CT Brain On contrast image nodular or ring‑like enhancing lesions
Solitary ring‑enhancing lesion in CT Brain
are seen. The diameter of these enhancing lesions usually
Common
ranges from 1 mm to 5 cm. The types of enhancement
Neurocysticercosis varies and may show complete ring, open rings, lobular
Tuberculoma patterns or may be irregular. Sometimes target lesions are
Less common found.[11‑14,16,17]
Pyogenic abscess
Glioma
Metastasis In the case of NCC, the appearance depends on the stage
Lymphoma of the lesion. The wall of the cysticercus granuloma
Toxoplasmosis (in immunocompromised host) (a colloid cyst stage) becomes thick and hypointense,
Cryptococcosis (in immunocompromised host)
Sarcoidosis
and there is mild to moderate perilesional edema on T2
Larva migrans image. Cysticercus granuloma also enhances and shows a
Cryptic AVM ring pattern after administration of contrast. Usually, the
CT: Computed tomography, AVM: Arteriovenous malformation lesions are <20 mm in diameter. Calcified eccentric scolex
if seen can be diagnostic of NCC in MRI. The lesions
Table 2: Spectrum of differential diagnoses of
are often multiple and most often do not have extensive
multiple ring‑enhancing lesion in CT Brain edema.[12,13,16,17,19]
Multiple ring‑enhancing lesions in CT Brain
• Molecular tests‑molecular tests like polymerase chain
Infective reaction based studies are very sensitive but cannot
Neurocysticercosis
Tuberculoma and tubercular abscess differentiate between infection and disease and also
Pyogenic abscess lack specificity and currently are not recommended
Syphilis as a diagnostic tool.
Nocardiocis
• Brain biopsy‑although histopathology accompanied by
Toxoplasmosis
Cryptococcosis tissue culture should be the gold standard for diagnosis,
Neoplasms it is not always feasible especially in the developing
Metastasis countries with limited resources.[17]
Primary brain tumors
Primary CNS lymphoma
Inflammatory and demyelinating diseases Newer imaging modalities for the diagnosis of tuberculoma
Sarcoidosis • Magnetic resonance spectroscopy
SLE Magnetic resonance spectroscopy of brain is a new
Neuro‑Behcet’s disease
and smart technique that measures the concentration
Whipple’s disease
Multiple sclerosis of several biochemical compounds in the brain
Acute disseminated encephalomyelitis in health and various disease states. In contrast to
CT: Computed tomography, CNS: Central nervous system, SLE: Systemic lupus conventional MRI showing images, MRS demonstrates
erythematosus
spectra of resonances. The area under each peak in the
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Flow Chart 1: Diagnostic algorithm for a solitary ring-enhancing lesion in computed tomography brain
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