What are the MRI features of neurobrucellosis in the brain and spine?

MRI Features of Neurobrucellosis in the Brain and Spine

The most characteristic MRI features of neurobrucellosis include leptomeningeal enhancement, vasculitis-related lesions, and granulomatous inflammation in the brain, while the spine may show spondylodiscitis, epidural abscesses, and arachnoiditis.

Brain MRI Features

Meningeal Involvement

• Leptomeningeal enhancement, especially at the base of the brain 1
• Diffuse or focal pachymeningeal enhancement
• Meningeal thickening with contrast enhancement

Parenchymal Lesions

• Vasculitis-related infarcts (both small and large vessel involvement) 2
• White matter lesions that may mimic demyelinating disease 3
• Granulomatous lesions that can appear as enhancing nodules 2
• Abscess formation (rare but reported, particularly in the pons) 2

Vascular Complications

• Small vessel vasculitis (most common vascular manifestation) 2
• Large vessel vasculitis 2
• Aneurysm formation (rare) 2
• Venous sinus thrombosis 3

"Red Flag" Features

• Inhomogeneous enhancement patterns that may mimic other inflammatory conditions
• Pseudotumor cerebri appearance 3
• Vasculitis patterns that can be confused with primary CNS vasculitis

Spine MRI Features

Vertebral and Disc Involvement

• Spondylodiscitis with T2 hyperintensity in the disc and adjacent vertebral bodies 4
• Endplate erosions with contrast enhancement
• Vertebral body marrow edema on T2-weighted images

Epidural and Intradural Involvement

• Epidural abscess formation with cord compression 4
• Spinal arachnoiditis 3
• Polyradiculopathy with nerve root enhancement 5
• Transverse myelitis 3

Spinal Cord Lesions

• Intramedullary lesions (less common)
• Transverse myelitis pattern with T2 hyperintensity 3

Diagnostic Considerations

Imaging Protocol

• Brain MRI should include:

  • T1-weighted pre- and post-contrast sequences
  • T2-weighted and FLAIR sequences
  • Diffusion-weighted imaging to detect early ischemic changes 4
  • Fat-suppressed post-contrast T1-weighted images for better visualization of leptomeningeal enhancement 4

• Spine MRI should include:

  • Sagittal T1-weighted pre- and post-contrast sequences
  • Sagittal and axial T2-weighted sequences
  • Fat-suppressed post-contrast T1-weighted images 4
  • Whole spine imaging when disseminated disease is suspected

Differential Diagnosis

• Multiple sclerosis (can be confused with white matter lesions of neurobrucellosis) 4
• Tuberculous meningitis (similar basal meningeal enhancement) 4
• Neurosarcoidosis (similar granulomatous lesions and leptomeningeal enhancement) 4
• Pyogenic spondylodiscitis (similar spine findings but typically more aggressive) 4
• Fungal infections (similar granulomatous lesions) 4

Clinical Correlation

• MRI findings should be correlated with:

  • Serum Brucella agglutination tests (titers ≥1:160 in endemic areas) 1
  • CSF analysis (lymphocytic pleocytosis, elevated protein, low glucose) 6
  • CSF culture or PCR for Brucella 6

• MRI findings may persist despite clinical improvement and should not be the sole determinant for treatment duration 6

Key Points to Remember

• Neurobrucellosis has varied MRI presentations that can mimic other neurological diseases
• Combination of meningeal enhancement and vasculitis is highly suggestive in endemic areas
• Spine involvement may occur with or without brain involvement
• MRI with contrast is essential for proper evaluation of both brain and spine involvement 4
• Follow-up MRI may be needed to assess treatment response, though radiological improvement often lags behind clinical improvement

Remember that neurobrucellosis should be considered in the differential diagnosis of patients with unusual neurological manifestations, especially those from or who have traveled to endemic regions such as the Mediterranean, Middle East, Latin America, and parts of Africa 1.