Brainstem tuberculoma mimicking brainstem stroke: Crossed syndrome in a young female

Introduction: Tuberculosis (TB) involving the central nervous system (CNS) can present as tuberculoma and may mimic neoplasms or vascular lesions, particularly when the brainstem is involved. Early recognition is critical in endemic settings such as India.

Case presentation: A previously healthy female in late adolescence presented with a one-month history of headache followed by progressive left-sided weakness and multiple cranial nerve deficits, producing a crossed brainstem syndrome. Magnetic resonance imaging (MRI) of the brain revealed conglomerated ring-enhancing lesions in the midbrain and pons, accompanied by surrounding edema. Magnetic resonance spectroscopy (MRS) demonstrated a lipid–lactate peak. Cerebrospinal fluid (CSF) analysis and systemic laboratory investigations were within normal limits. Empirical anti-tubercular therapy (ATT) with adjunctive corticosteroids was initiated, with clinical improvement noted within two weeks and continued gains on follow-up.

Discussion: Brainstem tuberculoma can closely mimic brainstem stroke and other mass lesions. In endemic regions, characteristic MRI/MRS findings should prompt consideration of tuberculoma even when CSF findings are normal. Early treatment may prevent the need for invasive diagnostic procedures and improve outcomes.

Conclusion: Brainstem tuberculoma should be considered an important differential diagnosis in young patients presenting with crossed brainstem signs in TB-endemic regions. A combination of characteristic imaging findings and high clinical suspicion can support the early initiation of ATT with adjunctive corticosteroids, which, in this case, was associated with prompt and favorable neurological recovery.