结核性脑(脊髓)膜炎合并脊髓空洞症的临床及MRI特征

Clinical features and MRI findings of tuberculous meningitis associated with syringomyelia

目的总结结核性脑(脊髓)膜炎合并脊髓空洞症的临床以及MRI特点。方法回顾分析9例结核性脑(脊髓)膜炎合并脊髓空洞症患者的临床表现、脑脊液和MRI结果。结果平均发病年龄(26.30±8.30)岁,男女之比约为2:1;呈亚急性或慢性起病。首发症状以发热伴头痛或咳嗽,下肢乏力、麻木及大小便障碍(6例)为主,亦可继发于抗结核治疗结束后6个月至1年;症状与体征不对称,节段性分离性感觉障碍不典型。MRI表现为脊髓中央纵行"串珠"状、"腊肠"样、梭形或细长条形长T_1、长T_2脑脊液样信号,空洞内及空洞壁无强化;病变部位蛛网膜下隙变窄且伴脊膜强化;脊髓空洞呈多房性,可累及颈髓(5例)、胸髓(8例)、腰髓(6例)或颈胸腰髓同时受累(4例)。病情轻重程度与空洞直径和长度不平行。结论脊髓空洞症可为结核性脑(脊髓)膜炎早期或迟发性并发症。其临床表现可不典型,空洞以胸髓受累常见,具多房性、多节段特点,病情轻重程度与影像学改变可不平行。提高对该病的认识并及时行MRI检查有助于早期诊断。

Objective To summarize the clinical features and magnetic resonance imaging （MRI） findings of tuberculous meningitis （TBM） associated with syringomyelia. Methods Clinical records, cerebrospinal fluid （CSF） and MRI were analysed retrospectively in 9 patients with concurrent TBM and syringomyelia from May 2006 to May 2010 in Changsha Central Hospital. Results There were 9 patients （6 men and 3 women） with subacute or chronic onset of TBM associated with syringomyelia. The age of onset of these 9 patients were ranged from 16 to 43 years. Six patients had fever and headache or cough at onset who subsequently developed weakness and numbness of the lower extremities and （or） fecal and urinary incontinence 5-110 d later. Three TBM patients developed weakness and numbness of the lower extremities and （or） fecal and urinary incontinence 6 months to 1 year later after the completion of treatment with antituberculous drugs. There was no correspondonce between signs and symptoms. The characteristic segmental dissociated sensory disturbance was not typical. Before antituberculotic treatment, leukocyte count in CSF was moderately increased [（5-420）×10^6/L], protein level of CSF was increased （2.50-4.16 g/ L）, while the level of glucose （1.07-2.15 mmol/L） and chlorine （101-119） mmol/L in CSF decreased. After the treatment with antituberculous drugs, the protein level of CSF in 4 cases was still increased （0.72-1.55 g/L） while others became normal. Longitudinal lesions with different types such as bead-like, sausage-like, spindle-like or slender cavitates were found in the central of spinal cord. The cavitates showed long T1 and long T2 signals as same as signals of CSF and were not enhanced on MRI. At the lesion site subarachnoid space appeared narrowed. Spinal meninges revealed enhancement on enhanced MRI. The cavitates presented muhilocular in cervical cord （5 cases）, thoracic cord （8 cases）, lumbar cord （6 cases）, or cervical cord to lumbar cord （4 cases）. The severity was not parallel to the diameter as well as the length of the cavitates. Conclusion Syringomyelia can be an early or delayed complication of tuberculous meningitis.The clinical syndromes of tuberculous meningitis associated with syringomyelia may be atypical. The cavitates are mainly found in the thoracic cord and are usuallymuhilocular and multisegmental. The symptomatic severity may not be parallel to neuroimaging changes. Improving the understanding of this disease and performing MRI without delay are helpful for early diagnosis.