A 35-year-old man presents with fever, headache, and altered sensorium for 12 days. On examination, he has neck stiffness and right-sided lateral rectus palsy (6th cranial nerve). CSF shows glucose 1.8 mmol/L (serum 5.5), protein 3.2 g/L, and lymphocytic pleocytosis (180 cells, 95% lymphocytes). Which finding on contrast-enhanced MRI brain is most characteristic of tuberculous meningitis?

• A Leptomeningeal enhancement over cerebral convexities
• B Basal cistern exudates with hydrocephalus ✓
• C Ring-enhancing lesions in the corticomedullary junction
• D Diffuse cerebral edema with effacement of sulci

Explanation

Tuberculous meningitis classically shows thick basal cistern enhancement with exudates on contrast MRI, often accompanied by hydrocephalus due to CSF flow obstruction at the basal cisterns. Cranial nerve palsies (especially 6th nerve) are common due to basilar inflammation. Leptomeningeal enhancement over convexities is more typical of acute bacterial or carcinomatous meningitis. Ring-enhancing lesions at the corticomedullary junction suggest neurocysticercosis or toxoplasmosis, not TB meningitis.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.