Presenter: Dr. Deborah Pakpahan Supervisor: Dr. Reyhan Eddy Yunus, Sprad, M.SC

Presenter : dr.
Deborah Pakpahan
Supervisor : dr. Reyhan Eddy Yunus, SpRad, M.Sc

Background
• TB is one of the most devastating presentations of tuberculosis (TB),
which constitutes about 10% of all TB cases and is responsible for about
40% of the deaths of TB in developing countries.
• Previous study showed that stage of TBM, basal meningeal enhancement,

hydrocephalus, exudate and hypertension were related to stroke in TBM
patients.
Methods
Ethics and participants:
• Ethics : The study was approved by the ethics committees of Chongqing
General Hospital, China
• Participants:
Inclusion criteria:
a. Age 18 – 50 years
b. Diagnosed as TBM
c. Brain magnetic resonance imaging (MRI) data available
d. Available written informed consent (yg mau diteliti di inform consent
dulu)
Exclusion criteria:
a. patients with cerebral vascular risk factors, including history of
hypertension, diabetes mellitus, hyperlipidaemia, coronary heart
disease, atrial fibrillation, cerebral ischemic stroke and hemorrhage
b. Patient with history
Diagnostic criteria
• TBM
▫ Definite : if acid-fast bacilli seen in the cerebrospinal fluid
(CSF)
▫ Probable : if diagnostic score > 12 ( at least 2 points either
come from CSF or cerebral imaging criteria)
▫ Possible : if diagnostic score were 6 to 11
• Stroke
▫ The diagnosis of Acute ischemic stroke was based on
hyperintense on DWI and hypointense on apparent
diffusion coefficient (ADC)
Severity of TBM was graded into:
• Stage I, (GCS: 15) alert and oriented without focal neurological deficit
(defisit neurologis fokal)
• stage II, (GCS: 10–14) with or without focal neurological deficit or
(GCS: 15) with focal neurological deficit
• and stage III, GCS less than 10 with or without focal neurological
deficit
Cerebral imaging and diagnosis of stroke
 Cerebral MR examination were conducted in all patients at admission, and

repeated if patient had new neurological symptoms and signs during
treatment.
• The diagnosis of acute ischemic stroke was based on hyperintense on DWI

and hypointense on apparent diffusion coefficient (ADC).
• Patients were defined as stroke group and non-stroke group by their MRI
findings.
Outcome
• All patients receive routine anti-TB treatment
• Disability status was assessed by Modified Rankin Scale (mRS) at
discharge
• Clinical Outcome :
- Good : mRS = 0
- Intermediate : mRS = 1-2
- Poor : mRs = 3-5 or Death
Modified Rankin Scale for Measuring the Degree of Disability or
Dependence in the Daily Activities of People who experience a Stroke
MR Presentations of patients with TBM
TBM patient with acute ischemic stroke in basal ganglia (hyperintense in DWI
and hypointense in ADC)
TBM patient with hydrocephalus
TBM patient with multiple tuberculomas
TBM patient with basal and cerebellar meningeal
enhancement
Result
• 80 patients were diagnosed as TBM, twenty-eight patients were excluded
because of : (28 yg di excluded)
- 16 Overage
- 5 unavailable MRI data
- 3 history of stroke
- 4 hypertension
• 52 patients were included (52 yg msk penelitian) and 12 (23,1%) patients
had acute ischemic stroke
Result
• Compared to patients in non-stroke group, patients in stroke group were
older (35,9 + 10,8 years vs 28,4 + 9,3 years, p = 0,030)
• In CSF examination, patients with stroke had higher level of white blood
cell (median 83/μl vs 20/μl, p = 0,022)
• Basal meningeal enhancement was more common in patients with stroke

compared to those without stroke (66.7% vs 35.0%, p = 0,051)
• At discharge, patients with ischemic stroke had worse clinical outcome

(poor outcome: 33,3% vs 10%, p = 0,024)
Discussion
Results from many studies have demonstrated that :
• Risk factors of stroke in young TBM patients were not fully
understood.
• Age, CSF white blood cell and basal meningeal enhancement

were independent risk factors for stroke in young TBM
patients.
• CSF white blood cell and basal meningeal enhancement were

independent risk factors for stroke in young TBM patients,
supporting the contribution of inflammatory reaction.
Conclusions
About a quarter of young adults with TBM have acute ischemic stroke
which may be related with poor clinical outcome. Age, CSF white blood
cell and basal meningeal enhancement can predict the occurrence of
acute ischemic stroke in young adults with TBM.
Critical appraisal
PICO
P : Fifty-two patients with TBM
I : brain magnetic resonance imaging (MRI)
C : Patients were defined as stroke group and non-stroke group
O : About a quarter of young adults with TBM have acute ischemic stroke
which may lead to poor clinical outcome.
Are the results of the study valid ?
Was the diagnostic test evaluated in a Representative

spectrum of patients ?
Yes, the diagnostic test was evaluated in three stage of TBM.

Was the reference standard applied regardless of the index test
result ?
Yes, the reference standard (MRI ) was applied regardless of the index test
result (acute ischemic stroke in TBM) .
Was there an independent, blind comparison between the index
test and an appropriate reference (‘gold’) standard of diagnosis?
Yes, there was an independent, blind comparison between the

index test (clinical information) and MRI.
What were the result ?
● Are test charecteristics presented ?

MRI MRI Sensitivity (Sn) = 8 / 22 = 0,36
(+) (-)
Specificity (Sp) = 26/ 30 = 0,86
Stroke 8 4
PPV = 8/ 12 = 0,66
Non – 14 26
stroke
MRI is not sensitive enough but specific enough for diagnosing acute
ischemic stroke in tuberculous meningitis.
Were the methods for performing the test described in
sufficient detail to permit replication ?
● Yes, the MRI permits replication

Critical appraisal
Article’s excellences:
1. Cohort prospective study, the study included the homogeneity of recruited
young patients.
2. The results are reviewed with blinded method.
Article’s weakness:
1. The study was conducted in single center with inevitable selected bias.
2. Brain magnetic resonance angiography (MRA) was not analyzed in our study
as insufficient data, which may be related with stroke. It has been reported
that about 40% of TBM patients have abnormal MRA.
3. The sample size was small and only young patients were included which
reduce the external validity of our study.

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Presenter : dr.

Supervisor : dr. Reyhan Eddy Yunus, SpRad, M.Sc

• Previous study showed that stage of TBM, basal meningeal enhancement,

 Cerebral MR examination were conducted in all patients at admission, and

• The diagnosis of acute ischemic stroke was based on hyperintense on DWI

• Basal meningeal enhancement was more common in patients with stroke

• At discharge, patients with ischemic stroke had worse clinical outcome

• Age, CSF white blood cell and basal meningeal enhancement

• CSF white blood cell and basal meningeal enhancement were

Was the diagnostic test evaluated in a Representative

Yes, the diagnostic test was evaluated in three stage of TBM.

Yes, there was an independent, blind comparison between the

● Are test charecteristics presented ?

● Yes, the MRI permits replication

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