Original Article
Predictors of Stroke and Its Significance in the Outcome of Tuberculous Meningitis

https://doi.org/10.1016/j.jstrokecerebrovasdis.2008.11.007Get rights and content

Background and Aim

We sought to study the frequency and predictors of stroke in tuberculous meningitis (TBM) and its prognostic significance.

Design

This was an observational study in a tertiary care teaching hospital.

Methods

In all, 122 patients with TBM aged 4 to 82 years diagnosed on the basis of clinical, cerebrospinal fluid, and magnetic resonance imaging criteria were prospectively evaluated. Severity of meningitis was graded into stage I to III. Magnetic resonance imaging was done at admission and 3 months after treatment. Outcome was defined at 3 and 6 months as complete, partial, or poor. Predictors of stroke and its significance in long- and short-term outcome were evaluated.

Findings

A total of 55 patients had stroke; 42 at admission and 13 developed within 3 months of 4 drug antitubercular treatment. Strokes were ischemic in 54 (hemorrhagic transformation in 7) and hemorrhagic in one. Basal ganglia infarctions were present in 30, thalamic in 9, brainstem in 10, cortical in 27, and cerebellar in 4 patients. Stoke was multiple in 29 patients. In all, 38 patients had infarctions in anterior circulation, 7 in posterior, and 10 in both. Stroke was significantly related to stage of meningitis, hydrocephalus, exudate, and hypertension. No difference was found in clinical or laboratory parameters in early and late strokes. At 6 months, 28 patients died. At 3 months there were 21 patients lost to follow up and at 6 months there were 30 patients lost to followup. Outcome is based on the rest of the patients, ie. 101 patients at 3 months and 92 patients at 6 months.

Conclusion

Stroke occurs in 45% of patients with TBM both in early and later stage, mostly in basal ganglia region, and predicts poor outcome at 3 months.

Section snippets

Inclusion Criteria

Patients with TBM diagnosed on the basis of clinical, cerebrospinal fluid (CSF), and radiologic criteria were included. Investigations done in this study are routine in the management of TBM and are approved by our institutional hospital information service. The diagnosis of TBM was based on clinical, CT or MRI scan, and CSF criteria. The essential criteria included presence of meningitic symptoms comprising fever, headache, and vomiting for 2 weeks or more where malaria and septic and fungal

Results

There were 122 patients with TBM whose median age was 32 (range 4-82) years; 7 were children (<12 years) and 41 were older than 40 years. In all, 58 were female. The median duration of illness on admission to our institute was 8 months. Before admission to our institute, 76 patients were receiving antitubercular treatment for a median duration of 30 (2-120) days. A total of 55 patients had stroke during the course of illness and 67 did not. Sixteen patients developed infarct within the first

Discussion

In this study, 45% of patients with TBM had stroke, and stroke was associated with poor outcome at 3 months but not at 6 months. The frequency of stroke in TBM was reported in 28% to 50%.8, 13, 16, 17, 18 This wide variation in the frequency of infarction in TBM may be caused by differences in patient population and methodology. In our study, the diagnosis of stroke was based on MRI findings as the focal weakness may have insidious course in the background of protean manifestations of TBM.

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