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Neurology India, Vol. 52, No. 1, January-March, 2004, pp. 129-130 Letter To Editor Tuberculous granuloma of the spheno-clival region Shenoy SN, Raja A Department of Neurosurgery, Kasturba Medical College And Hospital, Manipal Code Number: ni04042 Sir, The clivus is one of the common sites for diverse pathological lesions.[1] Tuberculosis commonly involves the craniovertebral junction causing atlanto-axial dislocation.[2] However, primary skull base tuberculoma is extremely rare.[3] A case of primary spheno-clival tuberculoma without involvement of the craniovertebral junction is reported and the management is discussed. A 24-year-old, non-immunocompromised lady presented with history of progressive diplopia and inward deviation of both eyes for one month. Cranial nerve examination revealed paresis of both lateral recti. The rest of the neurological and systemic examination revealed no abnormality. Her hematological and laboratory examination revealed no abnormality. Chest X-ray was normal. CT scan revealed evidence of an isodense, minimally enhancing, destructive and expansive clival lesion [Figure - 1]. T1-weighted MRI images showed an isointense lesion involving primarily the clivus and sphenoid sinus and extending anteriorly into the nasopharynx. The lesion enhanced on Gadolinium. There was a central zone of necrosis. The craniovertebral junction was normal [Figure - 2 a, b]. The patient underwent a trans-ethmoidal decompression of the lesion. The lesion was firm in the periphery and was vascular. However, the central part of the tumor was cheesy and avascular. Histopathological examination of the specimen revealed characteristic features of a tuberculoma with Langerhan′s giant cells and epithelioid cells. Acid-fast bacilli could not be isolated. Postoperatively, the patient was treated with antituberculous treatment [ATT]. The patient progressively improved and her abducens nerve function recovered completely. ATT was continued for 18 months. Repeat cranial CT scan showed complete disappearance of the lesion. Tuberculosis commonly involves the craniovertebral junction causing atlanto-axial dislocation.[2] Tuberculosis involving the clivus and sparing the craniovertebral junction is rare.[1],[3] The mycobacterium usually reaches the bone by hematogenous spread from a focus, usually in the lung.[4],[5] Although the exact mode of transmission of the mycobacterium is unclear, it could have been from the pharyngeal lymphoid tissues. Unlike the characteristic ring enhancement seen in cerebral parenchymal tuberculoma, skull base tuberculoma shows a diffuse enhancement and imaging characters mimic a malignant tumor, making the diagnosis of tuberculosis difficult.[4] Intraoperative frozen section examination can help in determining the surgical strategy. A high degree of clinical suspicion is also mandatory. References
Copyright 2004 - Neurology India The following images related to this document are available:Photo images[ni04042f2a.jpg] [ni04042f2b.jpg] [ni04042f1.jpg] |
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