ELSEVIER Infection CENTRAL NERVOUS SYSTEM TUBERCULOSIS: MEDICAL MANAGEMENT AND SURGICAL INDICATIONS Mitchell R. Gropper, M.D.*; Michael Schulder, M.D.t; Ashwini D. Sharan, B.A.f; and EunSook Cho, M.D.t *Division of Neurosurgery, Northwestern Memorial Hospital, Chicago, Illinois and fUniversity of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey Cropper MR. Schulder M, Sharan AD, Cho Es. Central nervous system tuberculosis: medical management and surgical indica- tions. Surg Neural 1995;44:378-85. BACKGROUND An increase in the incidence of tuberculosis in industri- alized nations has prompted a need for earlier diagnosis, treatment, and isolation of disease. An associated rise in the number of patients with central nervous system tu- berculosis (CNS TB) has forced neurosurgical services to reevaluate the indications for operative intervention. METHODS Seventeen cases of CNS TB were found in a retrospective review of all cases managed on the neurosurgical service between 1989 and 1994. These cases included eight with tuberculous meningitis, seven cases of supratentorial tu- berculomas, and two cases of infratentorial tuberculomas. RESULTS Major permanent neurologic morbidity was seen in one case (6%). Five patients (29.4%) died of complications associated with their primary disease. Eleven patients (64.6%) had excellent outcomes. All patients in the latter group completed an l&month course of antituberculous therapy. Cerebrospinal fluid shunts were necessary in three cases and emergent craniotomy was performed in three cases. Only four cases had human immunodefi- ciency virus (HIV) coinfection. CONCLUSION The neurosurgeon’s role in the management of CNS TB has once again become more evident. In the present series it is unclear as to whether this is due to multiple drug-resistant strains of Mycobacterium tuberculosis or HIV coinfection. It is clear, however, that vigilance over patient compliance and serial neurologic evaluation will determine the need for operative intervention. KEY WORDS Central nervous system, infection, Mycobacterium tuber- culosis, tuberculoma. Reprint requests to: Mitchell R. Cropper, M.D., Division of Neurosur- gery, Northwestern Memorial Hospital, Streetervllle Center, 233 East Erie, Suite 500, Chicago, Illinois 60611. Received June 2, 1994; accepted February 2, 1995. 0090-3019/95/$15.00 SSDI 0090-3019(95)00064-B I ncreasing drug resistance and a resurgence of mycobacterial infections in industrial nations has prompted a renewed interest in proper treatment regimens against these organisms. An estimated 1.7 billion individuals are infected with Mycobucterium tuberculosis worldwide with an annual infection rate of 11.1 per 100,000 reported in the United States [4]. Furthermore, an increasing number of patients in- fected with human immunodeficiency virus (HIV) are experiencing mycobacterial infections [ 181. It is in these individuals, as well as others who reside in close proximity to infected individuals (e.g., in- mates of correctional institutions and the home- less), where an increased incidence of tuberculous infection is being identified [8,11,14,18,25]. Fifteen percent of the 4000 cases of extrapulmo- nary tuberculosis reported in the United States each year involves the brain or spinal cord [23]. Of these patients, tuberculous meningoencephalitis or spinal column disease are common, and an occa- sional case of intracranial tuberculoma has been reported [ 13,22,24,31]. Intracranial tuberculomas are usually observed in patients with miliary tuber- culosis. At our institution 17 cases of intracranial tuberculosis have been diagnosed and treated over the past 6 years. We herein report the management of these patients. CASEREPORTS TUBERCULOUS MENINGITIS Eight patients were initially admitted with the diag- nosis of communicating hydrocephalus. All patients were evaluated with computerized tomography (CT) with and without contrast enhancement. Stan- dard tuberculin tests, chest radiographs, and pul- 0 1995 by EIsevIer Science Inc. 655 Avenue of the Americas, New York, NY 10010