Persistent Brain Tuberculomas after Standard Antituberculous Therapy: A Systematic Review of Radiological Persistence, Treatment Duration, and Clinical Outcomes

Persistent magnetic resonance imaging (MRI) abnormalities after treatment of intracranial tuberculomas create uncertainty regarding the optimal duration of antituberculous therapy (ATT). We systematically reviewed evidence on treatment duration, persistent residual lesions, and factors leading to treatment prolongation from case reports, case series, and cohort studies reporting intracranial tuberculomas treated with ATT. The review included 124 reports describing 201 patients with intracranial tuberculomas, 39 reports of miliary brain tuberculomas, and 24 cohort studies. Complete radiological resolution at the completion of ATT occurred in 71 of 201 patients, whereas persistent residual lesions remained in 83 of 201, and there was progressive disease in 11 of 201. Paradoxical reactions developed in 94 of 201 patients and were the most common indication for treatment extension. Although 39 of 201 patients completed 12 months of ATT, 31 received 13 to 18 months, 28 received 19 to 24 months, and 24 received >24 months. Complete clinical and radiological recovery was achieved in 99 of 201, whereas 75 of 201 improved despite residual sequelae; recurrence occurred in only 7 of 201. Among the 24 cohort studies, 20 reported radiological outcomes. Of these, persistent residual lesions were reported in 16 studies, whereas 4 reported complete radiological resolution. Planned ATT ranged from 6 to 18 months, paradoxical reactions ranged from 3.4% to 51%, and mortality varied up to 23.1%. Persistent intracranial tuberculomas are common after standard ATT and frequently result in prolonged treatment. Our review indicates that persistent MRI abnormalities alone should not be used to determine treatment duration.