Craniovertebral Junction Tuberculosis: A Review of 29 Cases Anant Krishnan, Deepak Patkar, Tufail Patankar, Jeshil Shah, Srinivasa Prasad, Troy Bunting, Mauricio Castillo, and Suresh K. Mukherji Purpose: The purpose of this work was to describe the various imaging findings in craniovertebral tuberculosis and the importance of imaging in treatment in these patients. Method: A retrospective review of MR and CT scans in 29 patients with cranio- vertebral tuberculosis was performed. The images were reviewed, paying special at- tention to both bony (skull base, atlas, and axis) and soft tissue involvement in addition to atlantoaxial dislocation, lateral subluxation of the dens, and compression of the spinal cord. Results: Suboccipital pain with neck stiffness was the most common presenting symptom in our patients. The skull was involved in 19 of the 29 cases, clivus involve- ment was seen in 11 patients, and occipital condyle involvement was present in 14 patients. Detailed analysis of atlas involvement due to tuberculosis showed the lateral masses to be predominantly affected. The dens was involved in 18 cases (62%). Soft tissue masses in the prevertebral area were seen in 22 patients, paravertebral in 27 patients, and epidural involvement in 25 patients was identified. Atlantoaxial displace- ment was present in seven cases, lateral mass-dens subluxation in five, and superior subluxation of the dens through the foramen magnum compressing the medulla was seen in two cases. Spinal cord compression with intrinsic cord changes was noted in 12 cases. All patients received multidrug antituberculous therapy for 1 year. The presence of neurologic deficit and instability of the atlantoaxial complex was pivotal in further management in these patients. Conclusion: A high degree of clinical suspicion is necessary when confronted with patients with neck stiffness and tenderness over the upper cervical vertebrae. MRI in these patients provides a sensitive method for the diagnosis of craniovertebral tuber- culosis. Index Terms: Craniovertebral junction—Tuberculosis—Magnetic resonance imag- ing. Tuberculosis of the cervical region is uncommon and accounts for only 10% of all cases of spinal tuberculosis (1). Isolated involvement of the craniovertebral region comprising the atlas, axis, and basiocciput is even rarer. However, in developing countries, this constitutes an in- creasingly important cause for craniocervical junction instability and cervicomedullary compression, necessi- tating early intervention. With the resurgence of tuber- culosis in the population following the spread of HIV, this is of greater importance. It has been reported that skeletal involvement has been noted in nearly 60% of tuberculosis cases in HIV-infected patients (2). Whereas reports have been available since the 1970s, to date few have documented a large series of atlantoaxial involve- ment using a sensitive imaging technique such as MR. Here we describe the imaging findings in 29 patients who presented with tuberculosis involving the craniover- tebral junction. MATERIALS AND METHODS We retrospectively analyzed the imaging findings in 29 cases of tuberculosis of the craniovertebral junction diagnosed and managed at our institution between 1987 and 1998. Diagnosis was based on isolation or culture of Mycobacterium tuberculosis (n  4), histologic evi- dence of caseation and granulomatous changes (n  10), and/or adequate response to antituberculous therapy (n  15). From the Departments of Radiology, King Edward Memorial Hospital (A. Krishnan, T. Patankar, and S. Prasad) and Dr. Balabhai Nanavati Hospital (D. Patkar and J. Shah), Bombay, India; and De- partments of Radiology and Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, U.S.A. (S. K. Mukherji, T. Bunting, M. Castillo). Address correspondence and reprint requests to Dr. S. K. Mukherji at Department of Radiology, University of Michi- gan, 1500 E. Medical Dr., UH B1510-0030, Ann Arbor, MI 48109- 0030, U.S.A. Journal of Computer Assisted Tomography 25(2):171–176 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia 171