Third Ventricular and Interpeduncular Fossa Tubercular Abscess With Triventriculomegaly-Ventriculoscopic Surgical Management

Intracranial tuberculomas are rather common lesions in developing world.Tuberculomas are usually located in cerebellum, basal ganglia and cerebral hemispheres, particularly in frontoparietal region.Less common sites include the corpus callosum, quadrigeminal plate,the cerebellopontine angle, the retro-orbital region, the anterior optic pathway and the supraseller region.The central nervous system (CNS) involvement comprises approximately 10–15% of all tuberculous infections.Brain tuberculosis is usually parenchymal. Intraventricular tuberculosis is very rare and only little number of cases has been reported. Intraventricular tubercular abscess is further rarer. Here we report a case of third ventricular tubercular abscess with triventriculomegaly that was managed by ventriculoscopic drainage and third ventriculostomy though preoperative diagnosis & surgical planning was


Introduction:
Intracranial tuberculomas are rather common lesions in developing world. 6In India,20% of all intracranial space occupying lesions are tuberculomas. 3Tuberculomas are usually located in cerebellum, basal ganglia and cerebral hemispheres, particularly in frontoparietal region. 3Less common sites include the corpus callosum, quadrigeminal plate,the cerebellopontine angle, the retro-orbital region, the anterior optic pathway and the supraseller region. 3The central nervous system (CNS) involvement comprises approximately 10-15% of all tuberculous infections. 8Ventricular involvement in neurotuberculosis can occur in different ways.Juxta ependymal focus of Rich causes meningitis by rupturing into the subarachnoid spaces.It may also cause variable degree of inflammation of the ependyma of the ventricular surface and the choroid plexus with formation of tubercle, tuberculoma and rarely abscess.Well formed intraventricular tuberculoma is extremely rare and only a few cases have been recorded.However, intraventricular tubercular abscess has rarely been reported. 9ird Ventricular and Interpeduncular Fossa Tubercular Abscess With Triventriculomegaly -Ventriculoscopic Surgical Management FORHAD HOSSAIN CHOWDHURY, 1 MD.RAZIUL HAQUE, 2 MD SARWAR MORSHED ALAM 3

Abstract:
Intracranial tuberculomas are rather common lesions in developing world.Tuberculomas are usually located in cerebellum, basal ganglia and cerebral hemispheres, particularly in frontoparietal region.Less common sites include the corpus callosum, quadrigeminal plate,the cerebellopontine angle, the retro-orbital region, the anterior optic pathway and the supraseller region.The

central nervous system (CNS) involvement comprises approximately 10-15% of all tuberculous infections.Brain tuberculosis is usually parenchymal. Intraventricular tuberculosis is very rare and only little number of cases has been reported. Intraventricular tubercular abscess is further rarer. Here we report a case of third ventricular tubercular abscess with triventriculomegaly that was managed by ventriculoscopic drainage and third ventriculostomy though preoperative diagnosis & surgical planning was different.
Keywords: Third ventricular., Tubercular abscess, Ventriculoscopic surgical management Here we report a case of third ventricular tubercular abscess with triventriculomegaly that was managed by ventriculoscopic drainage and third ventriculostomy though preoperative diagnosis & surgical planning was different.

Case presentation:
An 18 years old girl presented with headache, vomiting, visual disturbance, imbalance in walking.There was no history of convulsion, unconsciousness, menstrual or endocrine disturbance.She was drowsy but easily arose able.Her higher psychic functions including memory were normal.There was bilateral papilloedema.Visual acuity and field of vision were normal.Other neurological examinations including cranial nerves revealed no abnormality except imbalance during walking.Other systemic examination revealed no abnormality.MRI of brain showed a 1.5x1x0.5 cm hyperintance mass (that did not enhanced further after .contrast injection) in the floor of third ventricle with triventriculomegaly (Figure1A&B).The lesion was approached for biopsy by neuro-endoscope through right sided Kocher's burr hole with the hope to put a ventriculoperitoneal shunt through this hole.During biopsy taking pus and caseous material came out ( Figure2A,B,C,D,E,F).The pus and caseous material was removed & washout.Finally it was possible to make a ventriculostomy at the floor of third ventricle safely.Histopathology report was tuberculosis and she was put on antiTB.She recovered slowly.Her neurological examination revealed no abnormality at the end of 06 months after operation.Post operative MRI showed no residual lesion at the end of 18 months.the lesion.A necrotic caseous center surrounded by a capsule composed of fibroblasts, epitheloid cells, Langhans giant cells and lymphocytes is the picture of a tubercle under the microscope. 6re surgery is needed to establish a diagnosis and to exclude other possibilities (i.e.meningioma, lymphoma, metastesis).In our case we went for surgery to confirm diagnosis along with the hope for improvement of ptosis and 3 rd nerve functions.We only excised the tuberculoma in the cavernous sinus leaving the other tuberculomas in situ.Complete excision is not always necessary in tuberculomas in CNS. 7hough mainstay of treatment in intracranial tuberculomas is medical 7 but diagnosis is usually made after a surgical intervention.Overall mortality is 10%. 5

Conclusion:
In brain and skull base lesions one must not forget the possibility of tuberculosis which is a curable disease with appropriate surgical and medical management.

Discussion
Tuberculosis involving CNS is a serious condition with mortality and morbidity especially in developing countries.There is also resurgence in developed countries due to human immunodeficiency virus (HIV), immigration and development of multi-drug resistant strains. 6Central nervous system tuberculosis may appear as tuberculous meningitis, tuberculoma, abscess or Pott's disease. 4Tuberculomas account for 10-30% of all intracranial masses in developing countries, and 0.5-2% in developed countries. 2Common sites for tuberculomas are cerebral hemispheres and basal ganglia in adults, and in cerebellar hemispheres in children, due to the large blood supply to these areas. 6tients generally present with the complaints of ptosis, headache, and diplopia.Neurological examination reveals involvement of the cranial nerves contained within the cavernous sinus.Simultaneous involvement of other system is not common. 1There are no pathognomonic radiological findings for a tuberculoma, 1 so confirmation is only possible by histopathological study or by isolation of bacteria from

Fig.- 1 :
Fig.-1 : MRI of brain A-saggital view, B-axial view showing tuberculus lesion in the floor of third ventricle.

Fig.- 2 :
Fig.-2: A,B,C & D-per-operative endoscopic view of lesion in the floor of third ventricle during partial excision.E&Fperoperative endoscopic view of lesion after partial excision.