Predictors of stroke and its significance in the outcome of tuberculous meningitis

Abstract

Background and Aim: We sought to study the frequency and predictors of stroke in tuberculous meningitis (TBM) and its prognostic significance. Design: This was an observational study in a tertiary care teaching hospital. Methods: In all, 122 patients with TBM aged 4 to 82 years diagnosed on the basis of clinical, cerebrospinal fluid, and magnetic resonance imaging criteria were prospectively evaluated. Severity of meningitis was graded into stage I to III. Magnetic resonance imaging was done at admission and 3 months after treatment. Outcome was defined at 3 and 6 months as complete, partial, or poor. Predictors of stroke and its significance in long- and short-term outcome were evaluated. Findings: A total of 55 patients had stroke; 42 at admission and 13 developed within 3 months of 4 drug antitubercular treatment. Strokes were ischemic in 54 (hemorrhagic transformation in 7) and hemorrhagic in one. Basal ganglia infarctions were present in 30, thalamic in 9, brainstem in 10, cortical in 27, and cerebellar in 4 patients. Stoke was multiple in 29 patients. In all, 38 patients had infarctions in anterior circulation, 7 in posterior, and 10 in both. Stroke was significantly related to stage of meningitis, hydrocephalus, exudate, and hypertension. No difference was found in clinical or laboratory parameters in early and late strokes. At 6 months, 28 patients died. At 3 months there were 21 patients lost to follow up and at 6 months there were 30 patients lost to followup. Outcome is based on the rest of the patients, ie. 101 patients at 3 months and 92 patients at 6 months. Conclusion: Stroke occurs in 45% of patients with TBM both in early and later stage, mostly in basal ganglia region, and predicts poor outcome at 3 months.