PMC3992755_01
(a-c) Tuberculoma at the midbrain level iso and hypo intense on T1 and T2 respectively. (d and e) Hemorrhagic infarct at thalamus (right) and caudate nucleus. Axial section of the brain, (f) right thalamic hemorrhagic lesion extending from splenium through thalamus up to midbrain. (g) Right rostral pontine hemorrhagic lesion extending to the fourth ventricle. (h) Mid pontine level thrombosed vein (white arrow) and tuberculoma (right) (black arrow). (i) Microphotograph: Thromobosed veins and arteries entrapped in fibrin rich inflammatory exudate and extending into brain stem (H and E, xObj 2.5)
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F1
MRI brain [Figure 1a-e] revealed heterogeneous mixed signal intensity changes in the right thalamus, caudate, medial temporal region suggestive of hemorrhagic infarct with extensive perilesional edema extending into right internal and external capsules and corona radiata. On the surface the pontine and cerebellar veins were found thrombosed and enclosed in the exudate [Figure 1f-i].
PMC3992755_02
(a) Fluid-attenuated inversion recovery imaging (FLAIR) high parietal: Thrombosed cortical veins as hypointense linear structures. (b) FLAIR: Multiple subcortical hyperintensities. Few hypointense lesions in the bilateral frontal subcortical location (black arrow) probably tuberculomas. (c) Coronal FLAIR image showing hyper intensity in the bilateral temporal and left parietal subcortical white matter and in the pons. (d) Diffusion weighted imaging and (e) Apparent diffusion coefficient (ADC) map showing restricted diffusion in the right frontal sub cortical white matter. Note that not all the lesions which are hyperintense on diffusion weighted imaging are showing restricted diffusion on ADC
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F2
MRI revealed [Figure 2a-e] multiple subcortical hyperintensities in the bilateral frontal, parietal, temporal white matter and in the pons and midbrain region on T2 and FLAIR images.
(a) Thrombosed superficial cortical veins with hemorrhagic infarct (right). (b) Coronal: Large left parietal cortical subcortical hemorrhagic infarct. Inset histology: Thrombosed veins in subarachnoid space (H and E, xObj 5). (c) Axial (mid brain superior colliculus) tuberculoma in substantia nigra (arrow). (d) Histology: Cerebral cortex showing dense exudate along the sulcus entrapping the vessels with adjacent hemorrhage (H and E, xObj 2.5). Inset-Exudate with acid fast mycobacteria (Ziehl-neelsen xObj 40). (e) A pontine tuberculoma (corresponding to coronal fluid-attenuated inversion recovery imaging (H and E, xObj 5)
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F3
Autopsy confined to the examination of the brain alone was conducted 13 h after death following informed consent of the close relatives [Figure 3a-e].