Presentation
History of left cerebral lesion excision 1 year ago. Now severe headache and head swelling, suspected lesion recurrence.
Patient Data
Left temporoparietal giant space-occupying lesion measuring about 10.0 x 9.3 x 7.2 cm at its maximum TS, AP & CC dimensions. The lesion elicits a marginal low signal on T2 WI with a large necrotic center. It shows small areas of blooming effect on SWI likely secondary to paramagnetic material or microhemorrhagic foci. It also shows heterogeneous marginal post-contrast enhancement. The lesion is surrounded by large perifocal edema which together with the lesion exert a positive mass effect in the form of compression of the left lateral ventricle and protrudes extra-cranially through the left temporal craniectomy defect.
The left cerebral extra-axial space, the suprasellar and quadrigeminal cisterns show multiloculations likely secondary to adhesions sequel of prior surgical intervention.
MRS showed elevated Choline peak and Cho/Cr ratio. Reduced NAA peak and markedly elevated lipid/lactate peaks.
Pathology after excision shows extensively caseating tuberculous reaction. No malignancy.
Case Discussion
The patient had a history of excision of a similar lesion 1 year ago which was pathologically proven cerebral tuberculoma. The patient didn't receive any antituberculous drugs for 1 year with subsequent aggressive recurrent lesion at the same region.
In this case, surgical treatment was made to rapidly relieve the mass effect. It was then followed by antituberculous drugs.
Large-sized cerebral tuberculomas are reported a few times in literature. Giant cerebral tuberculomas could mimic neoplastic lesions.
Typical radiological features include low T2 signal, marginal ring enhancement, areas of blooming effect on SWI secondary to paramagnetic material, and prominent lipid-lactate peaks on MRS.
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