CEREBRAL VASCULAR COMPLICATIONS IN TUBERCULOUS MENINGITIS ON MRI AND MRA/MRV: NARRATIVE REVIEW.

Resumo

Introduction. Tuberculous meningitis (TBM) is the most severe form of extrapulmonary tuberculosis and may cause death or long -term neurological disability, especially when diagnosis and treatment are delayed. Basal meningeal inflammation and exudate can compromise cerebral vessels, leading mainly to arterial vasculitis with stenosis/occlusion and ischemic stroke, and less frequently to venous involvement such as cerebral venous sinus thro mbosis (CVST). Brain magnetic resonance imaging (MRI) combined with magnetic resonance angiography/venography (MRA/MRV) enables integrated assessment of meningeal, parenchymal, and vascular manifestations; however, published protocols vary in sequence sele ction, contrast use, angiographic technique, and reporting of acquisition details, which can affect sensitivity and interpretation. Objective. To synthesize recent literature on the application of brain MRI and MRA/MRV in TBM, focusing on vascular complications and practical protocol aspects, including useful sequences, acquisition parameters (when reported), technical limitations, and clinical implications. Methods. Narrative literature review with structured searches in PubMed/MEDLINE and LILACS/BVS (January 2020 to April 2026) using terms related to TBM, MRI, MRA, MRV, post- contrast FLAIR, DWI/ADC, vasculitis/stenosis/stroke, and CVST; search strings and dates were recorded, and predefined eligibility criteria were applied. Reviews (narrative and systematic), observational studies, and case series describing MRI/MRA/MRV findings and/or acquisition details were included. Results. Across studies, contrast -enhanced MRI commonly demonstrates basal leptomeningeal enhancement and may show hydrocephalus and infl ammatory lesions; conventional T1/T2 and FLAIR sequences support anatomical assessment, while pre -contrast FLAIR can help identify meningeal/exudative signal changes and CSF -related abnormalities. Diffusion-weighted imaging (DWI/ADC) is frequently highligh ted for early detection of small ischemic infarcts associated with tuberculous vasculitis. Post -contrast FLAIR is frequently described as improving visualization of basal cisternal/leptomeningeal enhancement because vessels enhance less, increasing the con trast between meninges and vascular structures. Susceptibility-weighted imaging (SWI) or T2* -weighted sequences may assist in evaluating hemorrhagic components in selected cases. On vascular imaging, MRA (time-of-flight or contrast- enhanced) often shows ar terial irregularity, multifocal narrowing, or occlusion associated with ischemic lesions; major pitfalls include flow -related signal loss and overestimation of stenosis in slow flow. MRV (time-of-flight or contrast- enhanced) can demonstrate venous sinus t hrombosis but requires careful interpretation because common anatomical variants (e.g., hypoplasia or atresia, particularly of the left transverse sinus) and slow flow can mimic thrombosis; correlation with structural images (T2/FLAIR and SWI) and evaluati on in multiple planes help reduce misclassification. Conclusion. MRI combined with MRA/MRV supports early recognition of both parenchymal and vascular complications in TBM and can inform clinical assessment. The evidence supports a practical “minimum” prot ocol (contrast MRI with DWI, adding targeted MRA/MRV when vascular complications are suspected) and an “extended” protocol with optimized angiography and advanced sequences when needed to improve characterization and reduce interpretative pitfalls.