CNS TB: Tuberculomas


  • A 32 years old man
  • No known medical illness
  • Presented with fever, cough and shortness of breath
  • CXR shows military pattern, sputum +ve for AFB
  • Had seizure while on anti-TB treatment (2 months after treatment)
Axial CT brain; non-contrast (upper rows) and post contrast (lower rows)

CT scan findings:

  • There are multiple ring enhancing lesions of various sizes in bilateral cerebral hemispheres, cerebellum and pons
  • The lesions demonstrate smooth thin wall and some of the lesions show clustering
  • There are various severity of surrounding perilesional oedema are seen
  • No abnormal leptomeningeal or basal enhancement
  • No hdyrocephalus

MRI findings:

  • There are numerous ring enhancing lesions seen in the cerebrum and cerebellum
  • The lesions are of various sizes and some lesions are clustered
  • Different signal intensities are observed of these lesions
  • Some lesions are hypointense on T1 and hyperintense on T2 weighted images, whereas others are iso on T1 and T2-weighted images
  • Some of the lesions show restricted diffusion
  • Hemo sequence shows minimal blooming artifact surrounding some of the lesions
  • Wedge-shaped area of restricted diffusion is also seen in the left parietal region that could represent infarction
  • Compression of ipsilateral lateral ventricles with mild hydrocephalus are seen
  • No leptomeningeal enhancement

Diagnosis: CNS tuberculosis with tuberculomas (proven via biopsy)


  • Tuberculoma is the most common parenchymal lesion in CNS tuberculosis which could be found in any portion of the intracranial space.
  • The lesion may be solitary or multiple and may be seen with or without meningitis.
  • MR Imaging findings of tuberculomas are varied depending on its three stages of maturation: noncaseating, caseating with a solid center and caseating with a liquefied center
  • Noncaseating tuberculomas generally exhibit hypointense signal on T1-weighted images and are hyperintense on T2-weighted and FLAIR images. They generally demonstrate homogeneous nodular enhancement on contrast-enhanced T1-weighted images.
  • Caseating lesions with a solid center appear relatively iso- to hypointense on both T1-weighted and T2-weighted images with an isointense to hyperintense rim on T2-weighted images, and with ring-like enhancement. The rim may be inseparable on T2-weighted images with the presence of peripheral oedema.
  • Caseating lesions with liquefied centers are hypointense on T1-weighted images and hyperintense with a hypointense rim on T2-weighted images, and show ring-like enhancement as well.
  • Complications of TB CNS include hydrocephalus, ischaemia and arteritis


Author: radhianahassan