title: Clinical and magnetic resonance imaging characteristics of tubercular ventriculitis: an under-recognized complication of tubercular meningitis.
abstract: BACKGROUND
  Ventriculitis also referred as ependymitis or ventricular empyema is a known complication of pyogenic meningitis. Despite high incidence of tubercular meningitis in developing countries, there are hardly any reports of tubercular ventriculitis.
  
  
  METHODS
  Five patients (four males and one female) of tubercular ventriculitis were retrospectively identified from December 2007 to August 2013. Their clinical features, cranial MRI characteristics, treatment offered, and outcome were reviewed.
  
  
  RESULTS
  The median age of 5 patients was 29 years (range 15 to 64 years). Two patients had preceding pulmonary/pleural tuberculosis and one had Pott's spine. One patient had multi-drug resistant tuberculosis. All five patients had papilledema, four had seizures, two had hemiparesis, and two had vision loss. On cranial MRI all patients showed contrast enhancement of ependymal wall of lateral/fourth ventricle with restricted diffusion and hydrocephalus; three showed intra-ventricular septations with sequestered ventricles, and two had ventricular sludge. Magnetization transfer (MT) images were available in only two patients. Both showed hyperintense epedymal wall on MT images. Four patients required ventriculo-peritoneal shunt and two underwent temporal lobectomy. Two patients with sequestered temporal lobe had acute deterioration in consciousness with signs of impending herniation and required urgent surgical intervention. Four patients recovered on anti-tubercular treatment over 18 months; one receiving secondary line ATT for residual brain abscess.
  
  
  CONCLUSIONS
  Tubercular ventriculitis is a rare complication of tubercular meningitis. MRI feature of sequestered ventricles/intraventricular septations and hyperintense ependymal wall on MT images could suggest tubercular etiology. Symptomatic hydrocephalus may require CSF diversion in most patients.
authors.affiliation: Department of Neurology, SGPGIMS, Raebareli Road, Lucknow, Uttar Pradesh 226014, India. Electronic address: prabhat_singhkgmc@yahoo.co.in.
authors.forename: Prabhat
authors.initials: P
authors.lastname: Singh
authors.affiliation: Department of Neurology, SGPGIMS, Raebareli Road, Lucknow, Uttar Pradesh 226014, India. Electronic address: dr_vimalkpaliwal@rediffmail.com.
authors.forename: Vimal K
authors.initials: VK
authors.lastname: Paliwal
authors.affiliation: Department of Radiodiagnosis, SGPGIMS, Raebareli Road, Lucknow, Uttar Pradesh 226014, India. Electronic address: zafar@sgpgi.ac.in.
authors.forename: Zafar
authors.initials: Z
authors.lastname: Neyaz
authors.affiliation: Department of Neurosurgery, SGPGIMS, Raebareli Road, Lucknow, Uttar Pradesh 226014, India. Electronic address: arunks@sgpgi.ac.in.
authors.forename: Arun K
authors.initials: AK
authors.lastname: Srivastava
authors.affiliation: Department of Pathology, SGPGIMS, Raebareli Road, Lucknow, Uttar Pradesh 226014, India. Electronic address: dr_rituverma@rediffmail.com.
authors.forename: Ritu
authors.initials: R
authors.lastname: Verma
authors.affiliation: Division of Neuroradiology, Department of Radiology, University of Pennsylvania School of Medicine, 219, Dulles Building, 3400 Spruce Street, Philadelphia, PA 19104, USA. Electronic address: drsuyash@gmail.com.
authors.forename: Suyash
authors.initials: S
authors.lastname: Mohan
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use; D058565:Cerebral Ventriculitis / Q000150:complications* / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery; D056424:Decompressive Craniectomy; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000150:complications / Q000473:pathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D059906:Neuroimaging; D012189:Retrospective Studies; D063189:Symptom Assessment; D016896:Treatment Outcome; D014390:Tuberculosis, Meningeal / Q000150:complications* / Q000188:drug therapy / Q000473:pathology; D017287:Ventriculoperitoneal Shunt; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents
keywords: Ependymal enhancement; Pyogenic ventriculitis; Sequestered ventricles; Tubercular meningitis; Tubercular ventriculitis; Ventricular sludge