Basal tuberculous meningitis complicated by middle cerebral artery vasculitis and subacute lenticulostriate infarction in a pediatric patient: MRI and TOF-MRA findings

Otmane Soussi; Khobzy Yousra; Daoud Bentaleb; Dalal Laoudiyi; Kamilia Chbani; Siham Salam

doi:10.5455/CRSM.20260223052620

Abstract
Introduction:
Tuberculous meningitis is a severe form of central nervous system infection and remains an important cause of neurological morbidity in children. Inflammatory exudates involving the basal cisterns may extend to adjacent intracranial vessels, resulting in arteritis and subsequent ischemic complications.
Case Description:
A 6-year-old girl presented with a one-month history of persistent headache and fever, followed by progressive right-sided weakness and dysarthria. Cerebrospinal fluid analysis showed lymphocytic pleocytosis, elevated protein concentration, and low glucose levels. Brain magnetic resonance imaging demonstrated nodular leptomeningeal enhancement predominantly involving the basal cisterns. Diffusion-weighted imaging showed reduced diffusivity within the left lenticulostriate territory. Associated FLAIR hyperintensity and contrast enhancement were consistent with late subacute infarction. Time-of-flight magnetic resonance angiography demonstrated irregularity of the M1 and M2 segments of the left middle cerebral artery, with attenuation of distal branches, suggestive of inflammatory vasculitis. Based on the clinical, biological, and radiological findings, tuberculous meningitis complicated by secondary vascular involvement was considered the most likely diagnosis.
Discussion:
This case illustrates the value of MRI/MRA in identifying ischemic complications of tuberculous meningitis. Recognition of arterial involvement is essential for appropriate management and may influence neurological outcome.

Key words: Tuberculous meningitis, Cerebral vasculitis, Middle cerebral artery, Lenticulostriate infarction, Pediatric stroke, MRI/MRA, Central nervous system tuberculosis