Atypical presentation of tuberculous vasculitis: dual large vessel occlusions leading to malignant ischaemic stroke

Tuberculosis (TB) is a significant global health challenge, particularly in developing countries. One rare complication of TB is vasculitis, involving inflammation of the blood vessels by Mycobacterium tuberculosis TB vasculitis typically results from the haematogenous spread of bacteria to the cerebral vasculature or extension from adjacent tuberculous lesions, such as tuberculomas. The pathogenesis includes direct invasion of vessel walls, leading to inflammation, luminal narrowing, thrombosis and ischaemic brain damage. Lesions usually affect smaller vessels or limited brain regions. This case involves a woman in her late 20s who presented with a decline in sensorium and was diagnosed with tuberculomas. Despite starting antitubercular treatment, her symptoms recurred a month later. Repeat imaging showed an increase in tuberculoma size, refractory to treatment, leading to a massive infarction in the region of the middle and anterior cerebral artery and ultimately her death. This case highlights the catastrophic neurological outcomes of TB vasculitis.