Clinical and magnetic resonance imaging characteristics of tubercular ventriculitis: an under-recognized complication of tubercular meningitis.

BACKGROUND

Ventriculitis also referred as ependymitis or ventricular empyema is a known complication of pyogenic meningitis. Despite high incidence of tubercular meningitis in developing countries, there are hardly any reports of tubercular ventriculitis.

METHODS

Five patients (four males and one female) of tubercular ventriculitis were retrospectively identified from December 2007 to August 2013. Their clinical features, cranial MRI characteristics, treatment offered, and outcome were reviewed.

RESULTS

The median age of 5 patients was 29 years (range 15 to 64 years). Two patients had preceding pulmonary/pleural tuberculosis and one had Pott's spine. One patient had multi-drug resistant tuberculosis. All five patients had papilledema, four had seizures, two had hemiparesis, and two had vision loss. On cranial MRI all patients showed contrast enhancement of ependymal wall of lateral/fourth ventricle with restricted diffusion and hydrocephalus; three showed intra-ventricular septations with sequestered ventricles, and two had ventricular sludge. Magnetization transfer (MT) images were available in only two patients. Both showed hyperintense epedymal wall on MT images. Four patients required ventriculo-peritoneal shunt and two underwent temporal lobectomy. Two patients with sequestered temporal lobe had acute deterioration in consciousness with signs of impending herniation and required urgent surgical intervention. Four patients recovered on anti-tubercular treatment over 18 months; one receiving secondary line ATT for residual brain abscess.

CONCLUSION

Tubercular ventriculitis is a rare complication of tubercular meningitis. MRI feature of sequestered ventricles/intraventricular septations and hyperintense ependymal wall on MT images could suggest tubercular etiology. Symptomatic hydrocephalus may require CSF diversion in most patients.