Stroke thrombolysis in tuberculous meningitis

A woman in her 30s presented with sudden onset right-sided weakness, speech difficulties and transient loss of consciousness. She had a medical history of migraine, hypothyroidism and cervical lymphadenopathy. On examination, her National Institutes of Health Stroke Scale (NIHSS) score was 8 due to dense right-sided hemiparesis. CT brain imaging showed no intracranial haemorrhage but revealed incidental findings of left supraclavicular and cervical lymphadenopathy. CT intracranial angiogram did not show large vessel occlusion. She received thrombolytic treatment for ischaemic stroke. NIHSS improved to 3 with no immediate complications. Following admission, she developed swinging fever, seizures and fluctuating right-sided weakness. Repeat MRI of the head showed leptomeningeal enhancement. Biopsy of the cervical lymph nodes showed histiocytic granulomatous lymphadenitis, which was suggestive of tuberculous meningitis (TBM). She was treated with quadruple antimicrobial therapy and steroids for TBM, as well as aspirin for ischaemic stroke, which resulted in good clinical improvement.