Elsevier

World Neurosurgery

Volume 110, February 2018, Pages 73-78
World Neurosurgery

Case Report
Case of Subarachnoid Hemorrhage Caused by Tuberculous Aneurysm

https://doi.org/10.1016/j.wneu.2017.10.128Get rights and content

Background

Subarachnoid hemorrhage caused by rupture of tuberculosis associated aneurysm is a rare complication. In this paper, we report a case of intracranial tuberculum with adjacent intracerebral inflammatory aneurysm which caused subarachnoid hemorrhage and brain abscess formation.

Case Description

A 28-year-old man presented with sudden onset of severe headache. He was diagnosed with pulmonary tuberculosis 8 years ago, and had been treated with antituberculosis medications for 6 months. Head computed tomography showed a small hematoma in the left sylvian fissure with subarachnoid hemorrhage. Cerebral digital subtraction angiography was performed and no aneurysm was found. He was discharged after nonsurgical treatment. Three weeks later, he came back to our department with complaint of aphasia. Magnetic resonance images showed a cystic lesion with mass effect. During operation, we encounter the brain abscess and were surprised to find a middle cerebral artery aneurysm while dissecting. The abscess was totally removed, and the aneurysm was secured by clipping. The aneurysm was suspected of being inflammatory in nature and associated with the patient's tuberculosis.

Conclusions

Tuberculosis in the central nervous system may present as tuberculoma and tuberculous meningitis. Vasculitis secondary to tuberculous meningitis can cause infarcts, and, rarely, aneurysm formation. This case report illustrated a rare case of intracranial infectious aneurysm related to tuberculosis and complicated by hemorrhage and brain abscess.

Introduction

A 28-year-old male presented with sudden onset of severe headache, associated with nausea and vomiting. His head computed tomography (CT) examination showed a small hematoma in the left sylvian fissure with subarachnoid hemorrhage (Figure 1). He was diagnosed with pulmonary tuberculosis 8 years ago and had been treated with antituberculosis medications for 6 months with good compliance. He later discontinued the medicine by himself as the tuberculosis seemed to be cured. After admission, his chest CT revealed multiple patchy shadows (Figure 2). Cerebral angiography was performed, and no intracranial aneurysm was found (Figure 3). After 2 weeks of nonsurgical treatment, the patient recovered and was discharged. Three weeks later, the patient came back and presented with headache and aphasia. Brain magnetic resonance imaging (MRI) showed a round subcortical mass, which was 5 cm in diameter on the left temporal lobe. The lesion was hypointensive on both T1-weighted imaging and T2-weighted imaging, and a ring enhancement was found after contrast (Figure 4). The patient underwent surgical treatment. The operation was performed through pterional approach, and high intracranial pressure was noted after dural opening. In the process of dissection, we encountered a brain abscess that consisted of a thick fibrous wall and dark brown purulent liquid. After the exudate was evacuated and the wall of abscess was completely removed, we were surprised to find a saccular aneurysm, 6 mm in diameter, arising from M2 bifurcation of the left middle cerebral artery (Figure 5). The aneurysm was judiciously examined. As the neck was not wide and the shape was regular, the clipping procedure seemed to be quite straightforward. The aneurysm was occluded by a single clip and then the aneurysm wall was resected. The cyst fluid, abscess wall, and aneurysm tissue were sent to the laboratory for pathologic examination. CT examination, performed on the third day postoperatively, confirmed that the abscess was totally removed (Figure 6). Pathologic results showed the wall of the abscess consisted of fibrous connective tissue with severe chronic inflammation. Microscopically, the cystic wall was composed of many plasma cells, lymphocytes with neutrophils infiltration. The typical multinuclear giant cell response was also identified. The aneurysm tissue had similar characteristics that were mentioned earlier. In addition, eosinophils, foam cell infiltration, necrosis in some areas, and phagocytosis of hemoglobin-containing macrophages were observed (Figure 7A and B). Furthermore, a polymerase chain reaction test for tuberculosis was positive. Accordingly, the mass was confirmed to be a tuberculous brain abscess and tuberculous infectious aneurysm. The patient was subsequently treated by antituberculous medication for 12 months. Then he was reexamined by CT and MRI, which showed no recurrence of brain abscess and aneurysm (Figure 8A and B). The patient recovered gradually and completely.

Section snippets

Discussion

Although intracranial tuberculomas develops in 1% of all patients with active tuberculosis, few reports are available on aortic aneurysms that are associated with pulmonary tuberculosis or intracranial inflammatory aneurysms associated with tuberculous meningitis (TBM).1, 2, 3 Subarachnoid hemorrhage caused by rupture of tuberculosis-associated aneurysm is a rare complication, and only a few case reports has been published so far. However, most of the reports focus on the mechanism of

References (7)

  • U.K. Misra et al.

    Stroke in tuberculous meningitis

    J Neurol Sci

    (2011)
  • S.J. Griffiths et al.

    Intraventricular hemorrhage due to ruptured posterior inferior cerebellar artery aneurysm in tuberculous meningitis

    Childs Nerv Syst

    (2000)
  • P.K. Gupta et al.

    MR imaging and angiography in tuberculous meningitis

    Neuroradiology

    (1994)
There are more references available in the full text version of this article.

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Conflict of interest statement: We declare that we have no potential conflicts of interests on our findings.

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