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Case Report

Malignant middle‑cerebral artery territory

infarction in tuberculous vasculitis

1
1
1
Salvadeeswaran Meenakshi‑Sundaram , Sundararajan Srinivasan , Somalinga Nagendran Karthik ,
Suresh Pandi , Alagappan Periyakaruppan , Bharathi Sundar 1
2
1
1 Department of Neurosciences, Apollo Speciality Hospitals, Madurai 625020, Tamil Nadu, India.
2 Department of Radiology, Apollo Speciality Hospitals, Madurai 625020, Tamil Nadu, India.
ABSTRA CT
Intracranial large vessel involvement is an unusual complication of tuberculous meningitis. The authors report a 39‑year‑old female
presenting with an episode of seizure, followed by rapid decline in sensorium without prominent systemic features. An initial cranial
magnetic resonance imaging revealed tuberculomata and patchy infarcts. Despite antituberculous therapy, she progressively
worsened. A cranial computed tomography scan done following the worsening revealed a massive middle‑cerebral artery (MCA)
infarct. Unfortunately, the patient died in spite of decompressive craniotomy. Malignant MCA territory infarct is a rare and potentially
fatal complication of tuberculous meningitis.

Key words: Arteritis, malignant middle‑cerebral artery territory infarct, tuberculous meningitis

INTRODUCTION the referring hospital revealed multiple heterogeneously
enhancing nodular lesions of varying sizes involving right
Involvement of small and medium sized vessels of posterior parietooccipital and frontal subcortical and
the intracranial vasculature is well recognised in cortical regions with significant thickening of adjacent
tuberculosis. Large artery involvement is however a leptomeninges and exudates. These features were classical
rare manifestation of tuberculous vasculitis. Here, of focal cortical and subcortical tuberculomata with
we present the first reported case in the literature of cerebritis and leptomeningitis, especially on a background
a patient who presented with a malignant middle- of acid-fast bacilli detected in sputum. There was also
cerebral artery (MCA) territory infarct as a manifestation cerebral edema with effacement of the ventricular system,
of tuberculous vasculitis. sulci and cisterns and focal vasogenic edema around the
right parieto-occipital lesion with patchy areas of diffusion
CASE REPORT restriction representing arteritis-induced-infarcts.
Antituberculous drugs (isoniazid 300 mg/day, rifampicin
A 39-year-old female had presented to her general 600 mg/day, pyrazinamide 1500 mg/day and ethambutol
practitioner 15 days prior to this admission with a 800 mg/day), dexamethasone 8 mg twice a day and
history of cough with expectoration and fever. Sputum phenytoin (300 mg/day) were administered. Sensorium
stained with Ziehl-Neelsen stain revealed the acid fast had however gradually deteriorated, and she had become
bacilli morphologically characteristic of mycobacterium unresponsive since a day when she was transferred to
tuberculosis. A few days prior to this admission, she our hospital.
had had an episode of generalized tonic-clonic seizure
followed by progressive decline in sensorium. Cranial On examination, she was hemodynamically stable,
magnetic resonance imaging (MRI) [Figure 1a-c] done at pyrexial and anemic. Neurologically she was
comatose with decerebrate movements of right upper
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limb to pain. There were no meningeal signs. On
Quick Response Code: the oculocephalic maneuver, there was failure of
Website: adduction of right eye and upgaze was absent. Pupils
www.nnjournal.net
were 5 mm on the right side and 2 mm on the left
DOI: side. Optic fundi were unremarkable. Tendon reflexes
10.4103/2347-8659.139722 were brisk bilaterally, and plantars were extensors
on both sides. Investigations revealed: hemoglobin

Corresponding Author: Dr. Salvadeeswaran Meenakshi‑Sundaram, Department of Neurosciences, Apollo Speciality Hospitals,
Lake View Road, KK Nagar, Madurai 625020, Tamil Nadu, India. E‑mail: drsundarsms@gmail.com

Neuroimmunol Neuroinflammation | Volume 1 | Issue 2 | September 2014 95