Dural Tuberculoma Mimicking Meningioma: A Clinicoradiologic Review of Dural En-Plaque Lesions

doi:10.1016/j.wneu.2015.10.097

World Neurosurgery

Volume 88, April 2016, Pages 686.e1-686.e7

https://doi.org/10.1016/j.wneu.2015.10.097 Get rights and content

Background

Tuberculosis has long been a major health concern in developing countries and now has troubled developed world as well, owing to increase in patients with human immunodeficiency virus and immigration. Central nervous system tuberculosis accounts for approximately 1% of cases of tuberculosis. The pathologic presentation is varied, with intraparenchymal tuberculomas and pachymeningitis being the most common. Being a great mimicker, it simulates numerous diseases radiologically, and this is best realized when atypical forms are encountered. Here an atypical case of dural en-plaque tuberculoma is presented with comprehensive review of dural en-plaque lesions with their differentiating features.

Case Report

A 20–year-old man presented with features of increased intracranial pressure. On imaging, there was an enhancing dural-based lesion in the left frontoparietal region. In view of herniation syndrome, urgent surgical decompression of the lesion was performed. Histopathology showed features of tuberculosis. The patient is now asymptomatic with antitubercular therapy without any residual lesion at 6 months of follow-up.

Conclusions

Tuberculoma en-plaque is an unusual entity characterized by a plaque-like meningitic process without exudation. It is easily confused with meningiomas as can other dural-based lesions comprising benign to malignant neoplastic, infectious, and granulomatous lesions. A preoperative diagnosis is imperative to differentiate it at least from neoplastic lesions, which are usually curable with surgical intervention in contrast to tuberculosis, which needs only optimal chemotherapy in most of the cases. Knowledge of differentiating imaging features, in corroboration with clinical history and high index of suspicion, helps in a proper preoperative diagnosis and optimal patient treatment.

Introduction

Tuberculosis has long been a major health concern in developing countries and now has troubled the developed world as well, owing to the increase in patients with human immunodeficiency virus and immigration.¹ Being a great mimicker, tuberculosis simulates numerous diseases radiologically, and this is best realized when atypical forms are encountered. The recognition and understanding of different radiologic manifestations along with high index of suspicion in appropriate clinical settings are of paramount importance in diagnosing these cases. Differentiating it from other neoplastic lesions becomes a challenge to the clinician because of the different treatment strategies often followed, the former requiring conservative management with antitubercular drugs, and the later with surgical implications. This becomes a real problem particularly in developed countries, where tuberculosis is relatively rare and it is lower on the differential list.

Central nervous system tuberculosis constitutes approximately 1% of all tuberculosis, amongst which meningeal tuberculosis accounts for about 70%–80% of cases.² Mycobacterium tuberculosis is the etiologic agent in virtually all patients. It most commonly results from hematogenous seeding from distant active sites to the leptomeninges and cortical and subcortical areas. However rarely, direct spread also can occur from otomastoiditis, infected paranasal sinuses, or direct inoculation by trauma or craniotomy.2, 3 Intracranial manifestations of tuberculosis are protean, with intraparenchymal granulomatous lesions being the most common. Other common pathologic entities encountered are focal or diffuse pachymeningitis, vasculitis, tubercular abscess, or empyema. Dural involvement is distinctly rare, even in developing countries. Multiple cases of dural tuberuloma mimicking meningioma have been reported in the literature, highlighting the diagnostic difficulties (Table 1).1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 We present an atypical case of en-plaque tuberculoma and review the literature. We have tried to provide a comprehensive review of the dural en-plaque lesions with their differentiating points for better understanding and application in clinical situations.

Section snippets

Case Report

A 20-year-old man had history of intermittent fever and bifrontal headache of 5 months' duration, although the headache had increased in severity in the past month. He presented to the emergency department with severe holocranial headache and vomiting. On examination, he had papilledema without any focal sensory, motor, or cranial nerve deficits. An urgent computed tomography scan with contrast showed an enhancing dural based lesion in the left frontoparietal region with disproportionate edema

Discussion

The incidence of intracranial tuberculomas is decreasing as the result of improvements in chemotherapy. Chronic meningitis in the form of leptomeningial involvement and intraparenchymal tuberculomas are the most common lesions of central nervous system tuberculosis. About half of the intracranial tuberculomas have dural attachment; however, a broad attachment like en-plaque lesions is rare.¹

Tuberculoma-en-plaque is an unusual entity that was first described by Pardee and Knox in 1927 as a

Dural-Based Lesions: Beyond Meningioma

The differential diagnoses of the dural-based lesions are wide, with meningiomas classically occupying its major subset and at the other end of spectrum a wide variety of neoplastic and non-neoplastic lesions (Table 2).²¹ Many of these lesions share similar imaging characteristics as meningiomas; however, some distinctive imaging findings, specific history, and supportive laboratory findings often assist in reaching an appropriate diagnosis (Table 3).

Conclusions

There is a wide range of benign to malignant neoplastic, infectious, and granulomatous lesions apart from meningiomas that involve the dura. These are easily confused with meningiomas because of their similar imaging characteristics. Knowledge of differentiating imaging features, along with a corroboration of with clinical history and high index of suspicion, helps in a proper preoperative diagnosis and optimal patient treatment.

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An en-plaque tuberculoma mimicking meningioma: A case report and literature review
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Citation Excerpt :
Neurological manifestations of en-plaque tuberculomas largely depend upon location within the central neuraxis, however, nausea, vomiting, headache, seizures, focal weakness, neck stiffness, or general symptoms like fever and anorexia are common symptoms present in most patients [4,10,11,15,16]. The presenting symptoms can be broadly classified into symptoms of raised intracranial pressure with or without localizing neurological signs, or progressive neurological disability with no elevated intracranial pressure [4,14,16]. Signs and symptoms of tuberculosis other than the CNS are present in 30–50 % of cases [6].
CNS tuberculomas tend to be intra-axial in most cases but extra-axial lesions are also rarely encountered An en-plaque or dural-based tuberculoma is an extremely rare form of intracranial tuberculosis that mimics varieties of primary or secondary meningeal tumors. the neurosurgeon and other physicians involved in the management should be well versed with the clinical presentations and imaging features for prompt and accurate diagnosis as well as proper subsequent management.
A 40 years old female patient presented with a progressively worsening headache of 6 months duration associated with visual blurring of the left eye and behavioral change. Her physical was unremarkable and baseline laboratory investigations were in the normal range. MRI of the brain showed a right frontoparietal dural-based mass with heterogeneous contrast enhancement and moderate perilesional edema. Craniotomy and GTR of the mass was done with an impression of meningioma to rule out tuberculoma. Histopathology confirmed tuberculosis and the patient was discharged after initiation of Antitubercuos therapy.
Knowledge of the imaging features of en plaque tuberculoma is crucial for accurate preoperative diagnosis and optimal management of this rare entity. PCR and MRS can help consolidate the diagnosis at times of difficulty to differentiate from a meningioma.
Incidentally detected intracranial dural tuberculoma following head injury, should always be thoroughly investigated to avoid unnecessary surgery – A rare case report
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Intracranial Tuberculomas can present as space occupying lesions in brain. But incidentally detected dural tuberculoma in case of head injury are very rare and not reported yet. There is varied presentation of intracranial tuberculomas and can mimics or simulates various diseases radiologically.
A 35 year male presented as a case of head injury with severe headache and vomiting. On computerized tomography head, biconvex iso to hyperdense lesion was seen in left frontal region. It does not seem to be related to head injury, so further evaluation with MRI (Magnetic resonance imaging) brain was planned. MRI brain was suggestive of diffuse and extensive dural involvement in left frontal region with surrounding edema and en plaque meningioma was suspected. Patient was planned for operative intervention and an extensive dural based lesion was found, which turned out to be tuberculoma on biopsy. Patient was kept on antitubercular medications for 12 months.
Dural tuberculoma is an unusual lesion with difficult to differentiate on imaging from dural based lesions in cases of head injury. Diagnosis is required to differentiate from en plaque meningiomas as antitubercular therapy is only required in dural lesions as compared to en plaque maningiomas which requires surgery. Clinical history, neurological examination, radiological findings with high index of suspicion are required to diagnose dural tuberculomas.
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CNS lymphomas, on the other hand, rarely require radical surgical debulking and are usually treated with methotrexate chemotherapy after histopathological diagnosis of biopsied tissue. Conversely, atypical infection, such as tuberculosis or, in our case, coccidioidomycosis, can masquerade as meningioma but may be managed non-surgically.43 Although none of these features alone was specific, the presence of any of these imaging features or a combination of features should raise one's suspicion.
There are a wide variety of intracranial mass lesions, both benign and malignant, which can closely mimic meningioma on imaging. We present five characteristic imaging features that can alert the radiologist to consider other differential diagnoses. Of the five imaging characteristics that were rarely seen in meningiomas, but common and specific for meningioma mimics, absence of dural tail is the most common (83.7%). Homogeneous T2 hyperintensity or T2 hypointensity are seen in nearly half of meningioma mimics and osseous destruction and leptomeningeal extension are present in 40.5% and 21.6% of meningioma mimics, respectively. The distinction between meningioma and its mimics is important because a large portion of the meningioma mimics requires substantially different clinical and surgical management.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Case ReportDural Tuberculoma Mimicking Meningioma: A Clinicoradiologic Review of Dural En-Plaque Lesions

Background

Case Report

Conclusions

Introduction

Section snippets

Case Report

Discussion

Dural-Based Lesions: Beyond Meningioma

Conclusions

Neuroimaging Clin N Am

Surg Neurol

J Neurol Sci

Tuberculoma masquerading as a meningioma. Case report

J Neurosurg

Cranial epidural tuberculoma. A case report

Acta Radiol

Isolated meningeal tuberculoma mimicking meningioma: case report

Surg Neurol

Tuberculoma presenting as an en plaque meningioma. Case report

J Neurosurg

Tuberculoma mimicking meningioma of the falx cerebri. PCR diagnosis of mycobacterial DNA from formalin-fixed tissue

Clin Neuropathol

A case of an intracranial tuberculoma, mimicking meningioma, that developed during treatment with anti-tuberculous agents

No Shinkei Geka

A meningioma-mimicking tumor caused by Mycobacterium avium complex in an immunocompromised patient

Am J Surg Pathol

Tuberculoma en plaque: a case report [review]

Neurol India

Case Report
Dural Tuberculoma Mimicking Meningioma: A Clinicoradiologic Review of Dural En-Plaque Lesions