Initial Management at Presentation
- Antibiotics: Medical management with a four-drug combination (HRZE) in the initial phase followed by a two-drug combination (HR or HE) in the continuation phase for a minimum of 10 months is recommended (26). Therapy should be extended to at least 12 months for those patients who fail to respond, or if treatment interruptions have occurred for any reason (24). All patients with TB meningitis may receive adjunctive corticosteroids regardless of disease severity at presentation (41, 42).
TB tuberculoma of the CNS
- Antibiotics +/- steroids: Adequate anti-TB therapy with anti-edema measures such as dexamethasone and mannitol can preclude development of acute mass effects in the most cases. Most lesions completely disappear with conservative treatment.
- Surgery for diagnosis or failed medical management: Currently, the main indications for surgery are diagnostic confusion with astrocytomas, even after MR spectroscopy and other tests, and where there are features of an acute rise in ICP in spite of medical treatment. Stereotactic biopsy can be used to establish diagnosis. Some authors have advocated subtotal removal in this situation to help diagnosis and reduction of ICP, rather than attempt radical removal (27).
TB abscess of the CNS
- Surgery to decrease mass, then antibiotic: TB abscess occurs in only 4–8% of patients with CNS TB who are HIV negative but in up to 20% of patients with CNS TB who are HIV positive. The aim of surgical management is to reduce the size of the space-occupying lesion and thereby reduce ICP and eradicate the pathogen. Early surgical drainage and chemotherapy are considered the most appropriate treatment for abscess and can be therapeutic as well as diagnostic. Early anti-TB therapy must be considered in all cases of suspected TB abscess even before surgery to reduce the risk of postoperative meningitis (24).
- Treat early for best outcome: Outcomes are better with early surgery, especially in patients in the better grades. Repeated LPs, EVD, shunt surgery, and ETV have all been recommended for obstructive hydrocephalus (25).
- Steroids: Steroids are typically used at the time of presentation of the illness to deal with problematic elevation in the ICP and progressive neurological dysfunction until the anti-TB medications begin to control the disease and symptoms reverse.
- Follow closely with office visits: Patients are followed closely in the office to insure that the treatment has controlled the disease and that there are not signs of its failure.
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