Endoscopic transclival decompression for ventral brainstem tuberculous abscess: illustrative case

Area of Science:

• Neurology
• Neurosurgery
• Infectious Diseases

Background:

• Central nervous system (CNS) tuberculosis (TB) presents a significant global health burden with high morbidity and mortality.
• Common complications include stroke and hydrocephalus.
• Brainstem tuberculomas and abscesses are rare but challenging CNS TB manifestations.

Purpose of the Study:

• To report a case of complicated brainstem tuberculomas treated with urgent surgical decompression.
• To evaluate the efficacy of the endoscopic endonasal transclival approach (EETA) in managing brainstem tuberculomas.
• To highlight the distinct clinical entity of tuberculous abscesses in the brainstem.

Main Methods:

• An 18-year-old immunocompetent male with acute quadriparesis and decreased consciousness due to brainstem tuberculomas underwent urgent surgical decompression and drainage via EETA.
• Antituberculous therapy and corticosteroids were administered.
• Intraoperative findings included granuloma and inflammatory debris; Mycobacterium tuberculosis was confirmed molecularly.

Main Results:

• The patient experienced remarkable recovery from quadriparesis postoperatively.
• Multiple cranial nerve deficits (CNs VI, VII, and VIII) were noted.
• The EETA facilitated diagnostic biopsy and ventral brainstem decompression.

Conclusions:

• While CNS tuberculomas often respond to medical management, tuberculous abscesses, especially in the brainstem, necessitate urgent surgical intervention.
• Surgical treatment is crucial for relieving brainstem compression, reducing inflammation, and preventing stroke.
• EETA is a safe and effective approach for diagnosing and treating ventral brainstem lesions in CNS TB.