dynamic-content-widget-2541d77-11 – Chennai Neuroscience Foundation

TB (Tuberculosis) of the Brain

Tuberculosis (TB) is an infectious disease caused by a bacterium called Mybacterium Tuberculosis (MTB). It usually affect the lungs. With time, the bacterium can spreads to other parts of the body including the brain. TB can affect people all ages and sexes.

Introduction

In the brain, tuberculosis forms what we call a tuberculoma. Tuberculomas vary in size and shape. They may be single or multiple. In the mature form, a tuberculoma is firm, hard to touch, and grayish-yellow in color. Tuberculoma usually does not contain any blood vessel. A capsule of tuberculoma is a piece of compressed, damaged brain tissue. A neurosurgeon’s job is to take out these tuberculomas.

Types of Tuberculoma

If the TB proves difficult to deal with medically, then a neurosurgeon works on physically removing the tuberculomas from the brain. To do that, it is important to know what kind of tuberculoma one is dealing with.

Tuberculoma en plaque
This tuberculoma looks like a plaque. This type of tuberculoma has increased blood vessels (other tuberculomas don’t have blood vessels). Surgeon must keep this in mind while removign the plaque-like tuberculomas.
Tuberculous Abscess
These tuberculomas contain pus and resemble a brain abscess. This type of tuberculoma is common in India
Cystic Tuberculoma
These tuberculoma are in the form of a cyst. They are filled with clear yellow or cloudy green fluid, depending on the stage of infection. These tuberculomas are relatively rare.
Multiple Grape-like Tuberculomas
Very rarely, multiple, immature tuberculomas are observed. They group together, resembling a cluster of grape.
Mictotuberculomas
This type of tuberculoma is seen as a small disc or ring around 5mm to 7mm in diameter. These are common in India.
Calcified Tuberculomas
With time, a tuberculoma can calcify into a hard mass. Although calcified, they are still infectious.
Tuberculous Encephalopathy with an “Inconsequential” Tuberculoma
Sometimes, brain damage is seen in children with a small or no lession at all. This is usually because of an allergic reaction to some proteins relseased by the TB bacteria. In these cases, a biopsy of the brain tissue usually help to confirm the presence of TB.

Symptoms

Here are some of the common symptoms of Brain TB:

Fever
Seizures
Headache
Vomiting
Nausea
Gait problems
Speech Disturbances
Vision Problems
Weakness
History of exposure to lung TB
Evidence of TB elsewhere in the body

Investigations

Here is the usual set of investigations carried out to find out of one has TB and how it has affected the body.

Blood Test
ESR (Erythrocyte Sedimentation Rate) is usually raised when there is any kind of infection in the body, including TB. So, a doctor orders a blood test to determine the ESR. But TB is a tricky one. One can have TB even with normal ESR.
Mantoux Test
A protein component of TB bacteria is injected into the skin of the forearm. If one has TB, the injection site becomes red in color. Trouble with this test is that it can give false-positive results.
Chest X-Ray
TB very rarely occurs without a lung infection. So, when the doctor suspects presence of TB, they always order a Chest X-Ray to determine if there is evidence of TB in the lungs.
CT of the Brain
CT imaging of the brain helps the doctor/surgeon to idenitfy she size, shape, location and number of lesions (damaged patches of tissue) in the brain. CT can also visualize calcification clearly.
MRI of the Brain
MRI images help the doctor/surgeon to see the stages of brain lesions clearly.
Stereotactic Biopsy
Under the CT guidance, using a fine needle, a small portion of the affected brain tissue (lesion) is taken out and studied under a microscope. This help in definitive diagnosis of TB in the brain.

Treatment of the Brain TB

Doctors usually prefer to deal with TB medically. When that fails, or when the TB has already spread dangerously, a decision to surgically remove the TB affected tissue is preferred.

Medical Treatment

Medication that kill or stop the growth of TB bacteria are known as anti0tubercular drugs. Usually, an anti-tuberculor drug, combined with steroidal medications, lead to healing of the TB affected tissue in 10 to 12 weeks’ time. If the patch of affected tissue is large, then complete healing might take up to 6 to 8 months.

Surgical Treatment

Small and easily accessible tuberculomas (tissue hardened by TB) can be removed by excision.
With large tuberculomas, an ultrasonic aspirator (or CUSA) is used to suck out the TB affected tissue, without affecting the surrounding normal area.

Go here for more information on surgical treatment of Brain TB.

TB (Tuberculosis) of the Spine

Introduction

Types of Spinal TB

Depending on the location of the spine infected by the TB, there are four lesion (a lesion is a damaged tissue).

Paradiscal Type
This type of tuberculosis start on the edges of the vertebra (bone in the spinal cord) and then spread towards the center. Hence, it is called a paradiscal (around the disc) type.
Central Type
This tuberculosis starts in the centre of the spinal cord and spreads towards the edges gradually. Since the center of the vertebre is affected first, it leads to compression, collapse and deformities of the bone of the spinal cord.
Anterior Type
This type of tuberculosis usually affects the structure connecting two vertebral bones. So, this type of infection can spread up or down the spinal cord. This infection eats up the front and sides of the vertebral bones.
Appendiceal Type
This type of tuberculosis affects the structures providing back and side support of the vertebral bones.

Complications due to Spinal TB

Abscess (bag of pus) of the infection, inflamed (swollen) parts of the spinal cord, affected bone or vertebra can press on the nerves passing through the spine. When this happens, the part of the body served by these nerves (like arms, legs, etc.) become weak or paralyzed.

Symptoms

When the tuberculosis bacteria leave the lungs and enter the blood, infection starts. This has various responses in the body:

Fever
Weight loss
Muscle pain
Sweating at night
Lack of interest in eating

As the bacteria in the blood settle down on the backbone and start eating it up, the patient can experience the following:

Back pain
Spine stiffness
Sudden cramping pain in the back muscle
Mass felt in lower back
Angulation of the spine

If the infection is left untreated, the backbone is destroyed and pieces of the bone start pressing on the nerves of the spinal cord. This leads to symptoms like:

Weakness or paralysis of legs
Calf pain
Tingling sensation of the feet

Investigations

Here are the standard investigations the doctors conduct in order to assess the existence and nature of the disease:

X-Ray of the Spine
A simple X-Ray of the spine can quickly identify locations of the spine destroyed by the tuberculosis bacteria.
CT Scan of the Spine
Because it produces much more detailed images, aA CT Scan of the spine can pickup a spinal TB at an earlier stage than X-Ray
MR Imaging of the Spine
MRI clearly shows the effect of TB on the nerves. X-Ray or CT Scan can’t provide this information.

Treatment of the Spine TB

We are fortunate indeed to be living in the era of effective antibiotics. Before antibiotics, TB killed large number of people it injected. Mathematician Ramanujan was a famous victim of tuberculosis. Even with antibiotics, eradication of TB from the body takes a long time.

Medical Treatment

If the spread of the TB is not severe, anti-tuberculosis medication is used to stop and growth of tuberculosis bacteria and then to kill them. The treatment usually stretches for 6 to 9 months to obtain a complete cure.

Surgical Treatment

When patients with TB of the Spine do not respond to medical treatment satisfactorily, a surgeon physically removes tissue affected by TB. After this, the drug therapy is usually more effective.
In advanced stages of Spinal TB, where nerves are compressed, resulting in weakness of the limb or paralysis, a spinal decompression surgery is preformed to release the compressed nerves.

Go here for more information on surgical treatment for the TB of the Spine

Treatment Window

Early treatment can save ones spine, arms and legs. If left untreated, the bacteria eats up the back bone, causing compression of spinal nerves, leading to paralysis.

When something damages the trigeminal nerves, the face/forehead area becomes susceptible to severe pain. Solutions vary from chemically attenuating the pain nerves to repairing the nerve damage through surgery.

Introduction

There is a nerve bundle called trigeminal nerve. It controls the sensation and movement in our face.

The nerve bundle comes out of the rear side of the brain and divides into three branches. Each branch has two types of nerves. One for sensation and another for movement control (tri = three, geminal = two).

When something like an errant blood vessel, tumor, or an unknown reason damages these nerves, the part of the face supplied by the affected nerve become super-sensitive to pain. Even a light sensation, like washing the face or chewing something can feel like being stabbed.

This pain called by defunct trigeminal nerve is called “Trigeminal Neuralgia”.

In some cases, the pain can appear spontaneously, then vanish without warning, only to come back again after hours, days, weeks or months. This is identified as Type-1 Trigeminal Neuralgia or TN1. In other people, the pain exists as a persistent dull pain. This is called Type-2 Trigeminal Neuralgia or TN2.

People over 60 are more susceptible to it. Similarly, women have higher chances of getting this condition than men. The right of the face has 5 times higher chances of TN pain than the left.

Complication due to Trigeminal Neuralgia

Trigeminal Neuralgia is not a life-threatening disease. But when the pain attacks, patients excruciating and find it unbearable. Most of them can’t focus on day to day life. Some cannot even go to sleep.

Lack of focus, rest and sleep can seriously affect the patient’s quality of life. Also, if the patient is administered a long course of steroidal or pain-relieving medication, they have their own adverse side effects.

Symptoms of Trigeminal Neuralgia

Trigeminal neuralgia is marked by severe, sharp facial pain. Apart from this, patients may also experience:

Numbness over some areas of the face
Pins and needles sensation over the face
Increased facial sensitivity
Toothache
Sudden involuntary facial twitches

Investigations

Trigeminal Neuralgia is primarily diagnosed through clinical observations.

TN pain is seen in the area addressed by the trigeminal nerve. It can occur repeatedly, from fraction of a second to lasting up to 2 minutes.

The pain intense and sharp. It can be superficial or stabbing. It can be spontaneous or triggered by something specific.

Persons affected by trigeminal neuralgia try to protect their face from being touched. If the patient rubs or holds the face to lessen the pain, then it is probably not TN. The source of the pain may well be a toothache.

If there is some weakness in the jaw muscle or the eye doesn’t blink when the white of the eye is touched, then the TN is probably caused by something crushing on the Trigeminal nerve. To find out what is crushing the Trigeminal nerve, the doctor may order an MRI imaging study.

If there is no weakess in the jaw muscle, or the eye does blink when the cornea is touched, then it must be concluded that the source of TN is idiopathic (source unknown).

Treatment for Trigeminal Neuralgia

Based on the nature of the condition, multiple options are available for treating Trigemial Neuralgia.

Medical Treatment

All patients suffering form Trigeminal Neuralgia end up going on pain relieving drugs. This doesn’t correct the condition. It only treats the symptoms.

If a patient with multiple sclerosis reports of TN pain, then the MS drug lamotrigine may help them
If the patient has no known cause for TN, then they usually respond to anticonvulsant drugs.

Patient who don’t respond to medical treatment may be recommended for interventional or surgical treatment.

Interventional Procedures

Several interventional procedures are available for Trigeminal Neuralgia. Of these, Glycerol Rhizotomy is the most promising.

Glycerol Rhizotomy: Glycerol is injected at a particular point on the face. As the trigeminal nerve is bathed in glycerol, it selectively destroys the pain fibres that fire improper signals.

Radio Frequency Ablation: In this procedure, high frequency heat is used to target the traigeminal nerve and thereby the ability of the nerve to transmit pain is destroyed. The procedure is very effective but the pain may re-occur after 2 years.

Balloon Compression: With help of a tiny balloon, the part of the trigeminal nerve that transmits pain signals to the brain, is compressed. As the balloon is inflated, the nerve is compressed. Once the procedure is complete, the balloon is deflated and removed out of the skull. 9 out of 10 patients respond to this treatment procedure. However, recurrence is common.

Cryotherapy: In this procedure, nerve fibers firing improper signals are frozen, and deactivated.

Accupuncture: Placing acupuncture needles at specific points on the face, provides immediate relief from symptoms of neuralgia. This technique is much effective when combined with medical treatment with anticonvulsant drugs.

Surgical Treatment

Two surgical options are available for Trigeminal Neuralgia.

Microvascular Decompression: This is a minimally invasive procedure. It is used when a blood vessel compresses upon the trigeminal nerve. In this technique, using an endoscope, the blood vessel and nerve is simply separated using a teflon patch.

Gamma Knife Radiosurgery: This is a painless minimally invasive procedure that uses precise focused radiation beams to selectively deactivate pain fibers in the trigeminal nerve.

Treatment Window

Treatment should be initiated, as soon as the condition is identified, and the diagnosis confirmed. Delayed intervention results in frequent, severe pain attacks that interferes with day-to-day activities.