Referat TB CNS Syarif Mas'Ud
-
Upload
mohammad-syarif-masud -
Category
Documents
-
view
222 -
download
0
Transcript of Referat TB CNS Syarif Mas'Ud
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 1/18
REFERAT
Diagnose Complications of Tuberculosis Infection In The Central Nervous
System
Disusun oleh :
ohamma! Syarif as"u!
##$%$###&'
(epaniteraan (lini) Neurologi RS*D +asar Rebo
+embimbing :
Dr, Donny -, -ami! SpS
RS*D +ASAR RE./ 0A(ARTA
FA(*1TAS (ED/(TERAN
*NI2ERSITAS 3ARSI
INTR/D*CTI/N
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 2/18
Tuberculosis is a formi!able !isease 4orl!4i!e because of its highly infectious nature
an! propensity for latency, The increasing prevalence of tuberculosis in both
immunocompetent an! immunocompromise! in!ivi!uals in recent years ma)es this !isease a
topic of universal concern, The !isease has insi!ious onset an! can affect virtually any organ
system in the bo!y5 inclu!ing the central nervous system 6CNS7,
+athogenic organisms may reach the central nervous system by hematogenous
sprea! or local e8tension an! cause infections of the meninges 6meningitis75 infections of the
brain an! spinal cor! parenchyma 6encephalitis5 myelitis75 focal purulent collections 6brain
abscess5 sub!ural empyema5 epi!ural abscess75 or infections of the nerve roots 6ra!iculitis5
polyra!iculitis7, Depen!ing on the causative organism5 the infection may ta)e an acute5
subacute or chronic course an! may be self9limiting or !estructive an! lifethreatening,
any CNS infections can be treate! if !iagnose! in timely fashion, The cerebrospinal flui!
e8amination5 inclu!ing culture5 an! neuroimaging stu!ies 6CT an! RI75 together 4ith the
clinical fin!ings5 are generally sufficient to enable a !ifferentiation among bacterial5 viral5
mycotic5 an! parasitic pathogens an! a precise etiologic !iagnosis, In general5 antimicrobial
therapy is given on an empirical basis until the causative organism is i!entifie! an! the
treatment can be tailore! to it,
#, Tuberculous eningitis
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 3/18
Definition is an inflammation of the arachnoi! membrane5 piamater involving
cerebrospinal flui! cause! by Micobacterium tuberculosis,
This is the commonest manifestation of tuberculous infection of the nervous system, In
Children , it usually results from bacteraemia follo4ing the initial phase of primary
pulmonary tuberculosis, In adults, it may occur many years5 after the primary infection,
Follo4ing bacteraemia5 metastatic foci of infection Io!ge in:
#, eninges
%, Cerebral or spinal tissue
, Choroi! ple8us
Rupture of these encapsulate! foci results in sprea! of infection into the subarachnoi!
space, In a!ults5 reactivity of metastatic foci may occur spontaneously or result from
impaire! immunity 6e,g, recent measles5 alcohol abuse5 a!ministration of steroi!s7,
.rain an! spinal cor! meninges that protects covere! !elicate neural structures5
carrying bloo! vessels an! flui! secretion Cerebrospinal, eningeal consists of three layers5
• Duramater
Is the most outer membrane an! a fibrous layer of !ense an! strong5 that encloses the
spinal cor! an! cau!a e;uina,
• Arachnoi!
Is a thin sheath of connective tissue that non9vascular separating the !ura mater 4ith
+iamater,
• +iamater
is a thin sheath that is rich in bloo! vessels an! imme!iately 4rap the brain an!
spinal cor!,
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 4/18
Fig #, anatomy of the meninges membrane
T. is classifie! into stages accor!ing to the .ritish e!ical Research Council 6RC7
criteria
Stage I: +ro!romal phase 4ith no !efinite neurologic
symptoms,
Stage II: Signs of meningeal irritation 4ith slight or no
clou!ing of sensorium an! minor 6cranial nerve
palsy7 or no neurological !eficit,
Stage III: Severe clou!ing of sensorium5 convulsions5 focal
neurological !eficit an! involuntary movements,
Pathophysiology5 ost tuberculous infections of the central nervous system are
cause! by Mycobacterium tuberculosis, as a result of hematogenous sprea! from a primary
location5 either the lung or gastrointestinal tract, Initially5 small tuberculous lesions 6Rich"s
foci7 !evelop in the CNS5 either !uring the stage of bacteraemia of the primary tuberculous
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 5/18
infection or shortly after4ar!s, These initial tuberculous lesions may be inoculate! in the
meninges< the subpial an! subepen!ymal surface of the brain or the spinal cor!5 an! may
remain !ormant for years, 1ater5 rupture or gro4th of one or more of these small tuberculous
lesions pro!uces various types of CNS tuberculosis, The type an! e8tent of lesion !epen!
upon the number an! virulence of bacilli an! the immune response of the host, A tubercular
rupture into the subarachnoi! space results in T. meningitis< 4here as !eep lesions cause
tuberculoma or abscesses, T. meningitis may cause inflammatory changes in cranial=spinal
nerves an! the bloo! vessels, The inflammation of bloo! vessels 6vasculitis7 subse;uently
results in thrombosis an! infarction, -y!rocephalous can occur secon!ary to impe!ance of
CSF circulation an! absorption, The inflammatory e8u!ates may also surroun! the spinal
cor! pro!ucing tuberculous arachnoi!itis, Infre;uently5 infection sprea!s to the CNS from a
site of !iscal T.5 tuberculous otitis5 or osteogenic tubercular foci in the spine or cranial vault,
+athologically5 a tuberculoma is compose! of central core of caseous necrosis surroun!e! by
a capsule of collagenous tissues an! an outer layer of mononuclear inflammatory cells
6inclu!ing plasma cells > lymphocytes75 epitheloi! cells an! multinucleate! 1angerhans"
giant cells, A tuberculoma harbours fe4 tubercular bacilli 4ithin the necrotic center an! the
capsule, /utsi!e the capsule5 there is parenchymal e!ema an! astrocyte proliferation,
*nli)e caseous tuberculoma5 a tubercular abscess has purulent center rich in tubercular
bacilli5 an! lac)s epithelioi! giant cell granulomatous reaction in its 4all,
Fig %, +athophysiology Tuberculous eningitis
Clinical Features Tuberculous meningitis occurs in persons of all ages, Formerly it 4as
more fre;uent in young chil!ren5 but no4 it is more fre;uent in a!ults5 at least in the *nite!
States, The early manifestations are usually lo49gra!e fever5 malaise5 hea!ache 6more than
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 6/18
one9half the cases75 lethargy5 confusion5 an! stiff nec) 6'? percent of cases75 4ith (ernig an!
.ru!@ins)i signs, Characteristically5 these symptoms evolve less rapi!ly in tuberculous than
in bacterial meningitis5 usually over a perio! of a 4ee) or t4o5 sometimes longer, In young
chil!ren an! infants5 apathy5 hyperirritability5 vomiting5 an! sei@ures are the usual symptoms<
ho4ever5 stiff nec) may not be prominent or may be absent altogether, .ecause of the
inherent chronicity of the !isease5 signs of cranial nerve involvement 6usually ocular palsies5
less often facial palsies or !eafness7 an! papille!ema may be present at the time of a!mission
to the hospital 6in %$ percent of the cases7, /ccasionally the !isease may present 4ith the
rapi! onset of a focal neurologic !eficit !ue to hemorrhagic infarction5 4ith signs of raise!
intracranial pressure or 4ith symptoms referable to the spinal cor! an! nerve roots,
-ypothermia an! hyponatremia have been a!!itional presenting features in several of our
cases, In appro8imately t4o9thir!s of patients 4ith tuberculous meningitis there is evi!ence
of active tuberculosis else4here5 usually in the lungs an! occasionally in the small bo4el5
bone5 )i!ney5 or ear, In some patients5 ho4ever5 only inactive pulmonary lesions are foun!5
an! in others there is no evi!ence of tuberculosis outsi!e of the nervous system, In the
previously mentione! Clevelan! series5 4hich comprise! ? patients5 active pulmonary
tuberculosis 4as foun! in #5 inactive in &5 an! involvement of the nervous system alone in <
only % of the ? patients ha! nonreactive tuberculin tests5 some4hat !ifferent from the
general e8perience note! belo4, Among our a!ult patients5 tuberculous meningitis is no4
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 7/18
seen almost e8clusively in those 4ith AIDS5 in alcoholics5 an! in immigrants from the Far
East an! In!ia, /ne recent case 4ith an atypical organism occurre! in an other4ise healthy
local professor 4ho spent several months in East Africa, E8cept for the emergence of !rug9
resistant organisms5 the -I2 infection !oes not appear to change the clinical manifestations
or the outcome of tuberculous meningitis, -o4ever5 others !isagree5 insisting that the course
of the bacterial infection is accelerate! in AIDS patients5 4ith more fre;uent involvement of
organs other than the lungs, If the illness is untreate!5 its course is characteri@e! by confusion
an! progressively !eepening stupor an! coma5 couple! 4ith cranial nerve palsies5 pupillary
abnormalities5 focal neurologic !eficits5 raise! intracranial pressure5 an! !ecerebrate postures<
invariably5 a fatal outcome then follo4s 4ithin B to 4ee)s of the onset,
Fig , Nuchal nec) rigi!ty Fig B, 1asegue
Fig ?, (ernig Fig &, .ru!@in)i #
Laboratory Studies5 the most important is the lumbar puncture5 4hich preferably
shoul! be performe! before the a!ministration of antibiotics, The CSF is usually un!er
increase! pressure an! contains bet4een ?$ an! ?$$ 4hite cells per cubic millimeter5 rarely
more, Early in the !isease there may be a more or less e;ual number of polymorphonuclear
leu)ocytes an! lymphocytes< but after several !ays5 lymphocytes pre!ominate in the maority
of cases, In some cases5 ho4ever5 M. tuberculosis causes a persistent polymorphonuclear
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 8/18
pleocytosis5 the other usual causes of this CSF formula being Nocardia5 Aspergillus5 an!
Actinomyces 6+eacoc)7, The protein content of the CSF is al4ays elevate!5 bet4een #$$ to
%$$ mg=!1 in most cases5 but much higher if the flo4 of CSF is bloc)e! aroun! the spinal
cor!, lucose is re!uce! to levels belo4 B$ mg=!1 but rarely to the very lo4 values observe!
in pyogenic meningitis< the glucose falls slo4ly an! a re!uction may become manifest only
several !ays after the patient has been a!mitte! to the hospital, The serum so!ium an!
chlori!e an! CSF chlori!e are often re!uce!5 in most instances because of inappropriate AD-
secretion or an a!!isonian state !ue to tuberculosis of the a!renals, ost chil!ren 4ith
tuberculous meningitis have positive tuberculin s)in tests 6? percent75 but the rate is far
lo4er in a!ults 4ith or 4ithout AIDS: B$ to &$ percent in most series, The conventional
metho!s of !emonstrating tubercle bacilli in the spinal flui! are inconsistent an! often too
slo4 for imme!iate therapeutic !ecisions, Success 4ith the tra!itional i!entification of
tubercle bacilli in smears of CSF se!iment staine! by the iehl9 Neelsen metho! is a function
not only of their number but also of the persistence 4ith 4hich they are sought, There are
effective means of culturing the tubercle bacilli< but since their ;uantity is usually small5
attention must be pai! to proper techni;ue, The amount of CSF submitte! to the laboratory is
critical< the more that is culture!5 the greater the chances of recovering the organism, *nless
one of the ne4er techni;ues is utili@e!5 gro4th in culture me!ia is not seen for to B 4ee)s,
+CR5 by DNA amplification5 permits the !etection of small amounts of tubercle bacilli an! is
no4 4i!ely available for clinical use, There is also a rapi! culture techni;ue that allo4s
i!entification of the organisms in less than # 4ee), -o4ever5 even these ne4 !iagnostic
metho!s may give uncertain results or ta)e several !ays to !emonstrate the organism5 an!
they cannot be counte! on to e8clu!e the !iagnosis, For these reasons5 if a presumptive
!iagnosis of tuberculous meningitis has been ma!e an! cryptococcosis an! other fungal
infections an! meningeal neoplasia have been e8clu!e!5 treatment shoul! be institute!
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 9/18
imme!iately5 4ithout 4aiting for the results of bacteriologic stu!y, /ther !iagnostic
proce!ures 6CT5 RI7 may be necessary in patients 4ho present 4ith or !evelop raise!
intracranial pressure5 hy!rocephalus5 or focal neurologic !eficits, /ne or more tuberculomas
may also be visuali@e! 6see belo47, R angiography may !emonstrate vascular occlusive
!isease from granulomatous infiltration of the 4alls of arteries of the circle of Gillis an! their
primary branches,
Table #, Comparative Analysis of CSF in meningitis infective
+N
Count
1ymphocyte
Count
lucose +rotein Culture an!
microscopic
2iral
antibo!y
Acut bacterial
meningitis
H
2iral meningitis N atau N H
Tuberculosis
meningitits
N atau H
Fungal meningitis N atau N atau
H
Imaging Features /n CT scan5 the most common fin!ing in cranial tuberculous
meningitis 6CT.7 is obliteration of the basal cisterns by iso!ense or mil!ly hyper!ense
e8u!ate, After the a!ministration of contrast me!ium5 there is !ense homogeneous
enhancement of the basal meninges 6Figure '7, E8tension of the meningeal enhancement over
the surface of the cerebral an! cerebellar hemispheres may also be observe!, E8tension into
the ventricular system 4ith epen!ymitis may be seen as a linear enhancement along the
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 10/18
ventricular margin, Communicating hy!rocephalus5 the most fre;uent complication of
CT.5 usually cause! by obstruction of CSF flo4 by the meningeal e8u!ate in the basal
cisterns5 may also be seen at the time of !iagnosis, In non9contrast enhance! CT an! RI5
hy!rocephalus may be the only clue for !iagnosis at the initial presentation 6Figure 7,
Chest J9ray: Reveals changes of ol! or recent tuberculosis in ?$ > '$K of a!ults an! $K of
chil!ren,
Fig ', Tuberculous meningitis in a B9year9ol! 4oman, 6a7 Non9contrast enhance! compute!tomography scan sho4s effacement of the basal cisterns cause! by the presence of e8u!ate,
6b7 Contrast9enhance! compute! tomography scan sho4s !ense enhancement of the
thic)ene! inflame! basal meninges
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 11/18
Fig , -y!rocephalus in a B9year9ol! man 4ith cranial tuberculosis, A8ial T# 4eighte!
magnetic resonance imaging reveals !ilatation of the lateral ventricles.
Fig , iliary Tuberculosis
%, Tuberculomas
These are tumor9li)e masses of tuberculous granulation tissue5 most often multiple
but also occurring singly5 that form in the parenchyma of the brain an! range from % to #%
mm in !iameter 6Fig, #$7, The larger ones may pro!uce symptoms of a space9occupying
lesion an! periventricular ones may cause obstructive hy!rocephalus5 but many are
unaccompanie! by symptoms of focal cerebral !isease, In the *nite! States tuberculomas
are rarities< but in !eveloping countries they constitute from ? to $ percent of all intracranial
mass lesions, In some tropical countries5 cerebellar tuberculomas are the most fre;uent
intracranial tumors in chil!ren, .ecause of their pro8imity to the meninges5 the CSF often
contains a small number of lymphocytes an! increase! protein 6serous meningitis75 but the
glucose level is not re!uce!, True tuberculous abscesses of the brain are rare e8cept in AIDS
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 12/18
patients, In t4o of our patients 4ho presente! 4ith a brainstem tuberculoma5 there 4as a
serous meningitis that progresse! to a fatal generali@e! tuberculous meningitis,
Clinical feature are those of any intracranial mass< alternatively tuberculoma may present in
conlunction 4ith tuberculous meningitis, CT scan clearly !emonstratcs an enhancing lesion 9
but this often resembles astrocytoma or metastasis< tubcrculomas have no !istinguishing
features, RI is even more sensitive an! may sho4 a!!itional lesions, /ther investigations:
ESR5 chevt J9ray often fail to confirm the !isgnosis, A antou8 6++D7 test is usually
positive but a negarive test !oes not eliminate the !iagnosis, Ghen tuberculoma is suspecte!5
a trial of antituberculous therapy is 4orth4hile, Follo4 up CT scans shoul! sho4 a re!uction
in the lesion site. /ther patients re;uire an e8ploratory operation an! biopsy follo4e! bv
long9term !rug treatment,
Fig #$, A tuberculoma of the !eep hemisphere in a Caribbean emigrantto the *nite! States,
The mass behave! clinically li)e a primarymalignant brain tumor an! resemble! a tumor on a
ga!olinium9enhance! RI,
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 13/18
Fig ##, Caseating tuberculoma, A8ial T%G R image6a7 of brain sho4s profoun!ly
hypointense lesion in left frontal lobe6blac) arro47 4ith mar)e! perilesional oe!ema, The
lesion !emonstrates isointense core 4ith slight hyperintense rim on T#G image6b75 an!
thin peripheral ring enhancement on ga!olinium9enhance! image6c7, ultiple similar
lesions 4ere present involving both supra an! infratentorial compartments5 note similar
lesion in left occipito9parietal region64hite arro47,
, Tuberculous Spon!ylitis 6pott"s spine7
Chronic epi!ural infection follo4ing tuberculous osteomyelitis t he vertebral bo!ies,
This arises in the lo4er thoracic region5 can e8ten! over several segments an! may sprea!
through the intervertebral foramen into pleura5 peritoneum or psoas muscle, Tuberculous
Spon!ylitis is a lea!ing cause of paraplegia, In !eveloping countries5 spinal tuberculosis
affects younger age groups5 inclu!ing infants an! chil!ren, In !evelope! countries5 it mostly
affects the el!erly, -o4ever5 !ue to -I2 epi!emic5 its inci!ence hasincrease! among younger
age groups, The !isease has insi!ious onset an! in!olent course,
The lo4er !orsal an! lumbar spines are most commonly affecte!5 follo4e! by cervical
spine, The atlanto9a8ial region involvement is relatively uncommon, The !isease process
results from hematogenous sprea! of infection to the vertebral bo!y via paravertebral
venous ple8us of .atson, Infection usually begins in anterior part of vertebral bo!y 4ithin
the cancellous bone a!acent to the en! plate or anteriorly un!er the periosteum of the
vertebral bo!y, Destruction of en! plate allo4s the sprea! of infection to the a!acent
intervertebral !isc5 an! subse;uently to the a!!itional spinal segment, Subse;uent sprea! of
infection to other vertebral bo!ies may also occur via subligamentous route5 4ith sparing of
intervertebral !isc LFigure#%M, Thus the classic pattern of involvement of more than one
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 14/18
vertebral bo!y together 4ith the intervening !isc is seen in T. spine, S)ip lesions
are not uncommon, /ccasionally5 tuberculous spon!ylitis affects only one vertebral bo!y5
sparing the a!acent !isc, The pe!icle an! posterior element involvement is rare, The sprea!
of infection into the paraspinal tissues results in the formation of paravertebral soft tissue
inflammatory mass 6phlegmon7 an!=or fran) abscess LFigure#%M, Intraspinal e8tension is
also fre;uent, Neurological !eficits are commonly associate! 4ith spinal tuberculosis
of cervical region5 particularly 4hen cranio9vertebral unction or C#9C% spine is involve!,
The neurological !eficit is usually cause! by significant thecal or cor!
compression by !isplace! bony fragment5 epi!ural inflammatory mass an!=or abscess, Death
may occur !ue to atlanto9a8ial instability or cervico me!ullary compression,
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 15/18
Fig #%, Tuberculous spon!ylitis 6+ott"s spine7 4ith subligamentous sprea! of the !isease,
Sagittal T#G6a75 T%G6b75 an! Coronal T%G6c7 image of !orso9lumbar spine !emonstrates
primary involvement of D#%91# vertebral bo!ies an! the intervening !iscs 6thin 4hite
arro47 by the !isease process 4ith contiguous sprea! if the infection cranially 6to involve all
!orsal vertebrae7 an! cau!ally6to involve 1% vertebra7 along the subligamentous route6thin
blac) arro47 4ith sparing of intervening !iscs6e8cept at D#%91# level7, Note5 marro4 signal
intensity changes in all the involve! vertebral bo!ies5 an! an epi!ural phlegmon at D#%91#level causing locali@e! cor! compression 6thic) 4hite arro47,
B, Tuberculous yelitis
Infection of the leptomeningens results in an e8u!ate that encases the spinal cor! an! nerve
roots, This pro!uces bac) pain5 paraesthesia5 lo4er limb 4ea)ness an! loss of bo4el an!
bla!!er conrrol, Imaging may be normal 4hile CSF sho4s high protein5 lymphocytes an!
rarely aci! fast bacilli, This !isor!er is no4 more fre;uent in AIDS patients, The cervico9
thoracic segment of the spinal cor! is most commonly involve!, R Imaging features of T.
myelitis are similar to those of cerebritis, There is !iffuse cor! s4elling 4ith signal
abnormality,ost spinal cor! lesions appear as hyperintense on T%5 isointense to hypointense
on T#94eighte! images5 an! sho4 segmental enhancement on post contrast images
LFigure#%M, Differential !iagnosis inclu!es cytomegalovirus5 cryptococcus5 syphilis an!
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 16/18
lymphoma, 1aminnectomy an! meningeal biopsy may be re;uire! to establish !iagnosis,
Ghen suspecte!5 empirical theory 4ith antituberculous !rugs is appropriate
Fig, # Tuberculous yelitis, Sagittal T%G6a75 T#G6b7 an! post contrast6c7 RI of !orso9
lumbar spine sho4s !iffuse cor! s4elling an! e!ema appearing hypointense on T#G an!
hyperintense on T%G image an! sho4ing intense central contrast enhancement on postga!olinium images6thin 4hite arro47, These changes are better appreciate! 6thic) 4hite
arro47 on a8ial T%G6!75 T#G6e7 an! post contrast image6f7
?, Tubercular Abscesses
Tubercular abscess is a rare manifestation of CNS tuberculosis5 occurring in less than
#$K cases, They are foun! more fre;uently in el!erly an! immunocompromise! patients,
The patient is acutely ill 4ith focal neurological !eficit, T. abscesses have a more
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 17/18
accelerate! clinical course, /n imaging5 a T. abscess may be in!istinguishable from a
caseous tuberculoma 4ith central li;uefaction or a pyogenic abscess, -o4ever5 a T. abscess
is usually solitary an! larger than tuberculoma, +erilesional e!ema an! mass effect is more as
compare! to tuberculoma, /n CT an! RI LFigure M5 it is often multinucleate! an! sho4s
thin5 smooth peripheral 4all enhancement on post contrast images,
Fig #B, Tubercular abscess, A8ial T%G6a75 T#G 6b75 an! CER6c7 images of another patient
sho4s solitary ring enhancing lesions 4ith li;uifie! center5 involving right basal ganglia
region6arro47,
7/24/2019 Referat TB CNS Syarif Mas'Ud
http://slidepdf.com/reader/full/referat-tb-cns-syarif-masud 18/18
REFERENCES
(hoo 01S et al , %$$, Central Nervous System Tuberculosis, 0 -( Coll Ra!iol <& :%#'9%%,
1ilihata an! -an!ryastuti S, %$#B, Kapita Selekta kedokteran, e!ia Aesculapius, Fourth
e!ition, 0a)arta +usat,
1in!say ( et al , #', Neurology and Neurosurgery Illustrated. Churcill 1ivingstone, r!
E!ition, E!inburgh,
umentaler et al , %$$B, Neurology, Thieme, Bth revise! an! enlarge! e!ition, Ne4 3or)
Ropper A- an! .ro4n R-, %$$?, Adam and ictor!s "rincples o# Neurology. cra49-ill,
Eight e!ition, *nite! States of America,
Gil)inson 1 an! 1enno8 , %$$?, $ssential Neurology. .lac)4ell +ublsihing, Fourth
E!ition, *nite! States of America,
3oes Ronny, %$$, (apita Sele)ta Neurologi, a!ah a!a *niversity +ress, 3ogya)arta,
uger A, Tuberculosis, In: Schel! GN5 Ghitley R05 arra C5 e!itors, In#ections o# Central
Nervous System. +hila!elphia: 1ippincott5 %$$B, pp, BB#9,