Space occupying lesion in the brain– What is it_?
Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India.

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056, India.

Clinical Problem :
A 7 years old boy presented with fever and headache for 1 month, projectile vomiting for 15 days and altered sensorium for 1 day. There was no contact with a patient having tuberculosis. On examination, he had signs of raised intracranial tension. An MRI brain was done that showed obstructive lateral ventricle hydrocephalus with irregularly shaped heterogeneously enhancing periventricular masses in the antero-mesial aspects of both temporal lobes and in medial aspect of right occipital lobe with areas of vasogenic edema and leptomeningeal enhancement. A differential diagnosis of tuberculoma or a neoplasm was considered. The child’s condition was too unstable to do a lumbar puncture. A neurosurgery opinion was taken regarding biopsy of the lesion but was not considered, again due to unstable condition of the child.

Question :
How to differentiate between tuberculoma and other space occupying lesions_?

Expert Opinion :
MRI is frequently performed in patients suspected to have central nervous system space occupying lesions to help in differentiating tuberculoma and other causes. Sometimes, MRI features are similar and usually not useful for differentiation. MR spectroscopy {MRS} helps to differentiate tuberculoma from other infective granulomas. While the MRI uses signals from hydrogen protons to form anatomic images, the proton MRS uses this information to determine the concentration of brain metabolites such as N-acetyl aspartate {NAA}, choline {Cho}, creatine {Cr}, and lactate in the tissue examined. MRS of brain tuberculomas commonly detects peaks of lipids attributable to large lipid fractions in tuberculosis bacillus. It will also have increased choline levels and decreased N acetyl aspartate and creatine levels. The choline, creatine ratio is greater than 1 in tuberculomas. {1}
In our patient, MRS was done and samples from the right occipital lobe lesion were taken and compared with the normal right frontal parenchyma. In the occipital lesion, there was increase in choline relative to creatine and NAA. There was a lactate-lipid peak between 1.49 and 1.28 ppm suggestive of tuberculoma. The child was started on steroids and anti-tuberculous therapy. Once his condition stabilized, a cerebrospinal fluid examination was done which grew mycobacterium tuberculosis on culture, thus confirming the diagnosis.

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