Tuberculosis afeccting the central nervous sistem and spine: CT and MR imaging implications for diagnosis and treatment

Transcription

1 Tuberculosis afeccting the central nervous sistem and spine: CT and MR imaging implications for diagnosis and treatment Poster No.: C-1854 Congress: ECR 2012 Type: Educational Exhibit Authors: S. G. Trigo, L. Velloso, N. A. Gouvea; Rio de Janeiro/BR Keywords: Diagnostic procedure, Contrast agent-intravenous, MR, CT-High Resolution, Neuroradiology spine, Neuroradiology brain, Infection, Inflammation DOI: /ecr2012/C-1854 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 25

2 Learning objectives - To present tomografic (CT)and magnetic resonance MR) aspects of tuberculosis in spine, central nervous sistem and in meninges, highlighting the importance of these methods to the diagnosis of the disease. - To emphasize the main CT and MR tuberculosis aspects and their importance to the diagnosis of the disease Background Tuberculosis, caused by the bacilli Mycobacterium tuberculosis, is one of the most common infectious diseases of the world, remaining a very important public health issue, specially in underdeveloped countries. When the disease affects the central nervous system or the spine and their involucres, it become a very serious problem, because the high risk of death, implications and difficulties of the treatment and severity of the sequelae. It has been analyzed and reviewed the imaging features of cases of tuberculosis in the spine and in the central nervous system, diagnosed by high resolution CT or MR in our institution, a major public hospital, confirmed by acid-fast bacilli stain, culture or response to therapy. All these cases were diagnosed and treated in the state public health system, in Rio de Janeiro, Brazil. Intracranial tuberculosis results in meningitis and intracranial tuberculomas. Meningitis is more frequent, specially in children. In meningitis, there is a purulent exudate that fills the cisterns. The disease spreads through the subarachnoid space and causes vasculitis, secondary to the bacilli invasion in the Virchow-Robin spaces, most commonly in the basal ganglia, thalamic and hypothalamic regions. The spine is the most frequent site of osseous involvement in tuberculosis, the so called "Pott disease". The upper lumbar and lower thoracic spine and the anterior elements of the vertebra (specially the body) are the most commonly affected parts of the spine. The disease usually extends between two or more adjacent vertebral levels through the anterior or posterior longitudinal ligament or by penetration of the subcondral bone plate, causing the demineralization of the end plates of adjacent vertebral bodies. Posteriorly, there will be the involvement of the disc, collapsing the disc space, anterior wedging and gibbous formation. The sub ligamentous and paravertebral muscles spread lead to paravertebral abscess formation, one of the most characteristic findings of the spine involvement. Page 2 of 25

3 Imaging findings OR Procedure details The imaging findings characteristic of tuberculosis meningitis includes the visualization of the purulent exudate that fills the basal cisterns, associated to the strong enhacement of these region after contrast administration, both in CT and in MR, which is sometimes extensive to the spinal subarachnoid space, to the hemispheric fissures and over the surfaces of the brain (fig. 1 to 4).Infarcts can be detected in the basal ganglia, thalamic and hypothalamic regions. Tuberculomas represent the parenchymal form of the disease, often multiple in the cerebral and medular tissue, and appear as multiple punctate or ring-enhacing foci on T1W, more common above the tentorium (figs, 5 to 8 ). On T2W images, the lesions can have a variable signal. They can be iso or hypointense, problably due to the presence of paramagnetic material inside of them or, on the other hand, they can be hyperintense, depending on the degree of central liquefative necrosis (figs 9 and 10). Image findings of spinal tuberculosis includes demineralization of the end plates of two adjacent vertebral bodies, specially in CT scans. Posteriorly, the vertebra will collapse, wedge anteriorly, and we will notice the gibbous formation. When the process extends to the paravertebral soft tissue, will see a hypodense mass that highly enhaces after contrast administration (Figs, 11 to 14 ). The clue for diagnose spinal tuberculosis in MR includes hypointense vertebral body marrow on T1W, with loss of endplate definition, on both sides on the disc. Finally, the intervertebral space will collapse, the vertebral body will loose height and collapses too. These alterations extends to paravertebral soft tissue, including ligaments and paravertebral muscles, as the disease progresses, and a dissecting paravertebral abscesses, sometimes out of proportion to vertebral involvement, will be detected. After gadolinium injection, there will be a avid enhancement in the vertebral body (ies) and discs involved, as well as in the paravertebral soft tissue.( figs. 15 to 19 ) Images for this section: Page 3 of 25

4 Fig. 1: Basal cisterns filled with inflamatory exudate - FLAIR Page 4 of 25

5 Fig. 2: T1W-the basal cirtens filled with inflamatory exudate Page 5 of 25

6 Fig. 3: T1W - strong enhancement after contrast administration in basal cisterns and in the adjacent meninges and subarachnoid space Page 6 of 25

7 Fig. 4: T2W, the same level as figs. 1 to 3 Page 7 of 25

8 Fig. 5: T1W axial - nodular isointense lesions in the left basal ganglia and occipital regions Page 8 of 25

9 Fig. 6: The same level as fig. 5, after contrast administration, demonstrate the rim enhancement of the basal ganglia lesion Page 9 of 25

10 Fig. 7: T1W coronal - multiple nodular hipointense lesions with surrounding edema Page 10 of 25

11 Fig. 8: T1W coronal - multiple ring enhancement lesions, with surrounding hypointense edema Page 11 of 25

12 Fig. 9: T2W - nodular hyperintense lesions, due to a greater degree of central liquefative necrosis, with surround edema. Page 12 of 25

13 Fig. 10: T2W - more hypointense lesion, due to high cellular density and/or to the presence of paramagnetic material inside of it. Page 13 of 25

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15 Fig. 11: Coronal CT - demineralization of two adjacent vertebral bodies end plates Page 15 of 25

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17 Fig. 12: Sagital CT - two adjacent vertebral bodies end plates erosion Fig. 13: CT - coronal, after contrast administration - bone erosion of vertebral bodies end plates, soft tissue paravertebral abscess formation Page 17 of 25

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19 Fig. 14: Sagital CT, after contrast - bone erosion, soft tissue abscess formation Page 19 of 25

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21 Fig. 15: T1W precontrast sagital - adjacent vertebral hypointensity and vertebral bodies height loss Fig. 16: T1W sagital - strong enhancement after contrast administration, in the adjacent vertebral bodies, adjacent meninges and in the paravertebral soft tissues Page 21 of 25

22 Fig. 17: T1W axial - vertebral body destruction, paravertebral soft tissue abscess formation Page 22 of 25

23 Fig. 18: T2W, in the same level as fig.16, showing adjacent vertebral bodies end plates destruction, gibbous formation Page 23 of 25

24 Fig. 19: T2W coronal - vertebral body destruction and paravertebral soft tissue abscess formation Page 24 of 25

25 Conclusion Acknowledging of the imaging features of central nervous system and spinal tuberculosis is very important to allow the proper treatment as quick as possible, to avoid very serious sequelae and death. The recognition of these diagnostic characteristics is of high importance, because it will be possible to start the treatment even before the culture results are available, specially in a high suspicious population. Personal Information Silvana Guimarães Trigo, MD; Leonardo Velloso, MD RIOIMAGEM PROJECT - RIO DE JANEIRO - BRASIL ADÃO PEREIRA NUNES HOSPITAL to silvanatrigo@terra.com.br References - Tuberculosis:A Radiologic Review - Burrill, J; Christopher J.W; Bain, G.; Conder, G.; Hine, A.L.; Rakesh R.M. - Joshua Burrill, FRCR - Radiographcs - volume 27 - number 5- September-October Imaging of Extrapulmonary Tuberculosis - Engin, G.; Acunas, B.; Tunaci, M. Radiographcs - Volume 20 - number 2 - March-April Tuberculosis from head to toe - Harisinghani, M. G.; McLoud, T.C.; Shepard, J.A.O.;Ko, J.P.; Shroff, M.M.; Mueller, P.R. - Radioghaphcs - volume 20 - number 2 - March-April Barkovich, A. J. - Pediatric Neuroimaging - Fourth Edition - Atlas, W.S. - Magnetic resonance imaging of the brain and spine - Third Edition Page 25 of 25