Cerebral infarction complicating Tuberculous Meningitis (TBM)

Abstract

BACKGROUND: Cerebral infarction (CI) is a serious complication of TBM, which can be silent (silent CI) or symptomatic causing stroke (symptomatic CI). Data of topographical distribution and prognosis of CI complicating TBM are limited. The best treatments and preventive measures are unknown. METHODS: TBM patients managed from January 1997 to June 2003 were prospectively studied. Treatments were standard anti-TB regimens, and corticosteroids for stage 2 and 3 TBM. Initial CT brain was performed in all patients. Reassessment CT/MRI brain was performed at 3 months of therapy and for neurological deterioration or complications. Lacunar infarction (LI) was defined as subcortical, cerebellar or brainstem infarction with a diameter of 15 mm or less on CT/MRI. Large-artery infarction (LAI) was defined as a lesion >15 mm in diameter on CT/ MRI. Modified Barthel index (BI) < 12 at 1 year of therapy or mortality were criteria for poor outcome. Clinical features of patients with LI only and those with LAI were compared with Student’s t-test and Fisher’s exact test. RESULTS: Forty TBM patients were studied. Twelve (30%) had CI, 9 (23%) were symptomatic and 3 (8%) were silent. Age of the 12 patients with CI ranged from 18-85 years, 8 were men. Two had stroke at onset of TBM, and 7 had symptoms of meningitis before development of stroke after a mean interval of 40 days (range 0-128 days). Four (33%) patients had single CI while 8 (67%) had multiple CI. Five (42%) had LI only while 7 (58%) had LAI with or without coexisting LI. Eight (67%) had CI restricted to anterior circulation territory while 1 (8%) had posterior circulation CI only; 3 (25%) had both anterior and posterior circulation CI. Two patient died, both from extensive posterior circulation CI and 6 (50%) had BI < 12 at 1 year. Hence 8 (67%) patients had poor neurological outcome. There is no significant difference in clinical features between those with LI only and those with LAI, but patients with LAI might have increased risk of developing posterior circulation CI. CONCLUSION: CI is a common complication of local TBM patients (30%, symptomatic in 23%) which tends to be multiple with LAI being common. About two-thirds of these TBM patients had poor neurological outcome at 1 year.