Neurotuberculosis presenting as space occupying lesion (tuberculoma) within the brain parenchyma is commonly encountered in developing countries [1]. Tuberculomas occur due to hematogenous spread and are generally intra-parenchymal in location with extra-axial and intra-ventricular locations being rare [1-4]. We present a rare case of fourth ventricular tuberculoma.

A four-and-half year old female child presented in a semiconscious condition with a history of progressive severe headache, vomiting and double vision for one week and low grade fever for two months. There was no past history of tuberculosis. Fundus examination revealed papilledema; rest of the neurological examination was unremarkable. Chest X-ray was normal. MRI showed conglomerate ring enhancing lesions in the fourth ventricle with moderate hydrocephalus (Fig. 1) and leptomeningeal enhancement in the left temporal region. Surgical shunting of CSF was done by placing ventriculo-peritoneal shunt. CSF examination of the patient demonstrated elevated protein levels (310 mg/dL) and low sugar (38 mg/dL) with 90% lymphocytes. CSF culture yielded growth of Mycobacterium. Child was started on antituberculous treatment. The patient was symptom free after three months and treatment was continued for nine months.

Fig.1 Contrast enhanced MRI images, (a) coronal and (b) sagittal, showing conglomerate ring lesions (arrow) in the fourth ventricle causing hydrocephalus.

Common locations of intracranial tuberculoma are cerebral and cerebellar hemispheres. Other less preferred locations being quadrigeminal cistern, cerebellopontine angle and suprasellar region [1]. Extra-axial tuberculomas are rare and intraventri-cular lesions are even less often seen [1-4]. This phenomenon is likely due to ventricles being more immune towards various infections. The most likely route of ventricular infections is through choroids plexus by hematogenous spread [1]. In tuberculosis choroid plexus gets inflamed with formation of tubercles, which may enlarge and form intraventricular tuberculoma. Tuberculoma forma-tion in areas devoid of choroid plexus may be due to formation of subependymal tubercles.