Tuberkuloma of a brain
Tuberkuloma of a brain — the opukholevidny granulyomatozny education caused by penetration of causative agents of tuberculosis into cerebral fabrics. It is clinically shown by the all-brain and focal neurologic symptomatology characteristic of intracerebral new growths. The diagnostic program includes neurologic survey, ophthalmologic researches, consultation of the phthisiatrician, the analysis of a likvor, radiodiagnosis, cerebral MRT. The main method of treatment is surgical removal of a tuberkuloma against the background of antitubercular therapy with the subsequent rehabilitation.
Tuberkuloma of a brain
The Tuberkulom of a Brain (TB) represents a separate form of extra pulmonary tuberculosis with focal intratserebralny defeat. The synonymous name of pathology — a cerebral tubercular granuloma occurs in references on neurology. According to various data, the tuberkuloma makes 2,1-3,4% of all tumoral formations of a brain. The disease is characteristic of children's and teenage age, is more often observed at boys. In 90% of cases at patients tuberculosis of intra chest lymph nodes or lungs, in 18% – various forms of extra pulmonary tubercular defeat (tuberculosis of skin, intestines, kidneys) comes to light. At 50% of patients infectious process has disseminirovanny character.
Causative agents of an infection (tubercular mikobakteriya) get into brain fabrics in the hematogenic, limfogenny way mainly in a dissemination phase. As primary centers of an infection lungs and lymph nodes usually act, is much more rare — the centers in intestines, bodies of urinogenital system, bones, skin. In 8% of cases primary tubercular center does not manage to be revealed. The factors contributing to a dissemination of mikobakteriya are immaturity of a hematoencephalic barrier, the reduced immunity (owing to primary or secondary immunodeficiency, diabetes, hormonal therapy), endocrine reorganization.
Intratserebralny penetration of mikobakteriya is followed by formation of the focus of a chronic granulyomatozny inflammation surrounded with the capsule. The single solitary tuberkuloma is more often observed, the multiple centers are found in 23% of patients. In 80% of cases structures of a back cranial pole, usually — gemisfer of a cerebellum are surprised. In process of growth of a tuberkulom squeezes the IV ventricle, blocks ways of a likvoroottok that causes okklyuzionny hydrocephaly. At supratentorialny localization in hemispheres of a tuberkulom acts as the trigger of the epileptogenny impulsation leading to emergence of epileptic paroxysms.
Processes of an otgranicheniye and calcification cause clinical remission of a disease, new activation of a granulyomatozny inflammation is followed by aggravation of symptomatology. Morphologically the tuberkuloma represents the encapsulated education reaching diameter of 2-3 cm. Contents of focus are presented by the granulematozny fabric containing epitelioidny, lymphoid, huge cages, the changed cages of a cerebral parenchyma. At a certain stage of development in the center of education the zone of a kazeozny necrosis is formed. Sometimes contents of a granuloma have a liquid consistence.
Broad application of methods of neurovisualization, constant search of lifetime ways of diagnostics and tomographic features tuberkuly led to allocation of several types of tubercular granulomas taking into account their morphological structure. Classification is used mainly in MR-diagnostics, includes three main types tuberkuly:
- Nekazeozny — has homogeneous granulematozny contents of a dense consistence. On MRT in the T1 mode it is visualized as the hypointensive center, in the T2 mode — as hyper intensive focus. When contrasting uniform contrast strengthening of education is observed. The similar tomographic picture is characteristic of initial stages of TGM.
- Kazeozny — consists from is central the located center of the curdled necrosis surrounded with dense granulematozny fabric. At a tomography gives hypo - and an isointensive signal in both modes. Contrasting is followed by ring-shaped strengthening of the image.
- Liquid — on the center of education is liquid. The liquid tuberkuloma tomographic does not differ from brain abscess. Hypo - the izointensivna in the T1, T2 modes, is contrasted as a narrow ring. Differs in high signal strength on the diffusion weighed images.
Brain tuberkuloma symptoms
The tubercular granuloma can have the hidden, latent current without significant increase in the sizes. In similar cases the petrifitsirovanny tuberkuloma is found only at autopsy. Clinically demonstrating TGM are characterized by the symptomatology typical for cerebral tumors. Gradually all-brain and focal symptoms appear and progress, the deterioration periods wavy alternate with the periods of some improvement. At certain patients the debut of opukholepodobny manifestations is preceded by a sharp episode with rise in the body temperature expressed by all-infectious, all-brain and meningealny symptomatology. Further remains subfebrilitt also the easy meningealny phenomena, focal deficiency demonstrates 1-3 months later.
Growth of education is followed by the intra cranial hypertensia causing a headache, nausea, vomiting, stagnant disks of optic nerves. If the granuloma is localized in a back cranial pole near likvorootvodyashchy ways, outflow of a likvor is at a loss, hydrocephaly accrues. At an arrangement in hemispheres epileptic attacks are observed, it is frequent – paroxysms of dzheksonovsky epilepsy, generalized attacks. Tuberkuloma of frontal localization is shown by frustration of mentality, behavior, mental abilities. At defeat of a parietal share paresis, a gipesteziya, apraxia, aphasia is noted. The granuloma arrangement in left a temporal share leads to akustiko-Gnostic aphasia. At defeat subcrustal giperkineza are found.
Tuberkuloma of a cerebellum is characterized by symptoms of a cerebellar ataxy: unsteadiness of gait, an intentsionny tremor, nistagmy, disorder of coordination of movements, muscular hypotonia in gomolateralny extremities. Diskoordination of operation of the articulation device causes violation of the speech — the chanted pronunciation of words (a cerebellar dizartriya) deprived of intonation. At increase in formation of a cerebellum perhaps sdavleny a medulla, backs of the craniocereberal nerves leaving it with development of their dysfunction.
The progressing focal deficiency invalidizirut the patient. Okklyuzionny hydrocephaly is followed by likvorno-gipertenzionny crises with sharp increase in intrakranialny pressure, an intensive headache, repeated vomiting, impossibility to eat food. Special danger is constituted by the sdavleniye of a brain trunk developing because of hydrocephaly with the vital centers located in it. The epileptic status can become a complication of epileptic paroxysms. In some cases there is a rupture of TGM to infection of covers of a brain, developing of tubercular meningitis. Without timely treatment the last leads to a lethal outcome.
Diagnosing of a disease is difficult as clinical and tomographic pictures are similar to a cerebral tumor. TGM cases at the patients who do not have symptoms of a specific inflammation and instructions on earlier postponed tuberculosis are described. At most of patients of a tuberkulom comes to light during surgical treatment concerning a brain new growth. The list of necessary diagnostic actions includes:
- Collecting anamnesis. The postponed or current tuberculosis, presence of tuberculosis at the persons which are in continuous contact with the patient matters. It is necessary to pay attention to long subfebrilitt also other symptoms of a chronic infectious disease according to the anamnesis.
- Consultation of the neurologist. The research of the neurologic status confirms existence of the all-brain symptomatology indicating increase in intra cranial pressure, an easy meningealny syndrome. The nature of focal deficiency allows to assume process localization.
- Consultation of the ophthalmologist. Decrease in visual acuity is found. At an education arrangement in the field of a hiazma and optical paths the perimetry diagnoses loss or restriction of visual fields. At an oftalmoskopiya puffiness of disks of optical nerves is defined.
- Consultation of the phthisiatrician. It is carried out in the presence of a X-ray analysis of a thorax and results of tuberkulinovy test. The X-ray analysis gives the chance to reveal damage of lungs, primary tubercular complex. The bend of tuberkulinovy test demonstrates existence of active tubercular process. At a number of patients test within norm, sometimes — is negative.
- General blood test. The picture of moderate inflammatory changes is characteristic. It is noted small , the accelerated SOE, the shift of a leykotsitarny formula is possible to the left.
- Likvor research. The increased concentration of protein, moderated is found. Crops of a likvor on nutrient mediums seldom give growth of mikobakteriya as process is accurately delimited by the capsule. Definition of the activator in a likvor is more characteristic of generalized types of tubercular defeat of TsNS – meningitis, an encephalomeningitis.
- Skull X-ray analysis. In pictures signs of long increase in intrakranialny pressure are visible: manual vdavleniye on arch bones, osteoporosis of the Turkish saddle, a divergence of cranial seams. In the presence of calcification of TGM it is visualized on roentgenograms.
- Brain MRT. The careful complex research with use of T1/T2 of the modes, the diffusive weighed images is recommended, to MR-spectroscopy. The tuberkuloma is spoken well by small perifokalny swelled, existence of a cover, ring-shaped contrasting.
The differential diagnosis of TGM is carried out with primary and metastatic neoplaziya of cerebral localization. Often verification of the diagnosis is possible only by results of an intraoperative histologic research. The exception of other infectious damages of a brain having a similar tomographic picture is necessary: cysticercosis, toxoplasmosis, bacterial abscess, kriptokokkoz.
Treatment of a tuberkuloma of a brain
Neurosurgical removal of TGM is accompanied by an intraoperative obsemeneniye of surrounding fabrics mikobakteriya, the subsequent spread of an infection on likvorny ways with development of tubercular meningitis. Because of it before emergence of antitubercular medicines surgical removal of TGM came to the end with a lethal outcome in 82% of cases. Patients with the petrifitsirovanny educations and konveksitalny granulomas leading to limited meningitis survived. With the advent of antitubercular himiopreparat results of expeditious treatment significantly improved. In modern neurosurgical practice treatment of TGM includes four main stages:
- Antitubercular therapy. It is carried out in a complex and it is long by a combination of 2-3 pharmaceuticals. Streptomycin, rifampicin, an isoniazid is applied. In the post-operational period make endolyumbalny introduction of streptomycin.
- Neurosurgical removal. Operation is performed by neurosurgeons, access depends on localization, demands bone and plastic cranial trepanation. Education vylushchivatsya together with the capsule within healthy fabrics.
- Dehydrational therapy. For reduction of hydrocephaly, prevention of hypostasis of a brain in the postoperative period introduction of sulfate magnesia, purpose of diuretics is shown (furosemide, , ). In hard cases glucocorticosteroids are recommended.
- Rehabilitation. It is directed to restoration of the lost nervous functions. The medicamentous component includes the neyrotropny, neurometabolic pharmaceuticals improving food and functioning of nervous tissue. From non-drug methods the kinezioterapiya, massage of extremities, physiotherapy exercises is widely applied. Recovery of the speech is carried out by occupations with the logopedist.
Forecast and prevention
Timely removal of TGM against the background of active etiotropny therapy provides recovery of 75% of patients. Cases multiple cerebral tuberkuly, a rupture of education with development of sharp tubercular meningitis, the combined defeats of TsNS, the crushing combined damages of internals have the serious forecast. Primary prevention of TGM consists in identification, full treatment and the subsequent observation of TB patients, performing mass antitubercular vaccination of children. Secondary preventive actions assume regular observation of postoperative patients, control of a likvor in 2 weeks after the end of antitubercular therapy and in 6 months after operation.