Tesis

Kesesuaian gambaran radiologis dengan kriteria diagnosis pada pasien dugaan meningitis tuberkulosis di Rumah Sakit Cipto Mangunkusumo = Inter-test Agreement between Radiological Images and Diagnostic Criteria in Patients with Suspected Tuberculous Meningitis in Cipto Mangunkusumo Hospital.

Latar Belakang: Meningitis tuberkulosis (TBM) adalah manifestasi tuberkulosis (TB) ekstra paru terberat dengan mortalitas dan morbiditas mencapai 50%. HIV merupakan salah satu faktor risiko, dan Indonesia termasuk daerah endemis TB dan HIV. Diagnosis definitif TBM memiliki sensitivitas rendah dan kultur membutuhkan waktu lama. Pemeriksaan radiologi membantu diagnosis TBM melalui temuan di kepala, toraks, maupun organ tubuh lainnya melalui radiografi thorax: TB paru aktif, serta CT/MRI kepala dengan kontras: hidrosefalus, penyangatan sisterna basal dan fissura Sylvii, tuberkuloma, infark, dan hiperdensitas sisterna basal dan fissura Sylvii tanpa kontras. Berdasarkan konsensus oleh Marais et al (2009), didapatkan kriteria diagnosis TBM mencakup kriteria gambaran klinis, gambaran CSS, gambaran radiologi otak, serta temuan TB di luar otak. Saat ini di Indonesia dan RSCM, belum ada penelitian yang meneliti kesesuaian gambaran radiologi dengan kriteria diagnosis pada pasien dugaan TBM. Penelitian ini bertujuan untuk mengoptimalkan pemeriksaan radiologi pada pasien dengan dugaan TBM dan mengetahui kesesuaian diagnosis TBM berdasarkan pemeriksaan radiologi dengan hasil berdasarkan kriteria diagnosis TBM untuk membantu optimalisasi tatalaksana klinis. Metode: Studi kesesuaian, desain cross-sectional. Dilakukan consecutive sampling pada pasien penelitian dengan dugaan TBM yang memenuhi kriteria inklusi. Dilakukan penilaian terhadap keberadaan penyangatan sisterna basal dan fissura Sylvii, hidrosefalus, tuberkuloma, infark, perubahan CSS sisterna basal dan fissura Sylvii, dan TB paru aktif pada pemeriksaan CT atau MRI kepala dengan kontras intravena dan radiografi toraks oleh peneliti dan pembimbing radiologi. Kemudian dilakukan analisis dengan Kappa Cohen dan konkordansi. Hasil: Pada analisis Kappa Cohen, terdapat asosiasi lemah antara kombinasi komponen gambaran radiologi (0,29), infark (0,27), penyangatan sisterna basal dan fissura Sylvii (0,22), asosiasi minimal antara hidrosefalus (0,17), TB paru aktif (0,16), perubahan CSS sisterna basal dan fissura Sylvii (0,15), dan tuberkuloma (0,08), serta asosiasi negatif antara abses TB (-0,02) dengan kriteria diagnosis TBM. Pada analisis Konkordansi, terdapat kesesuaian sedang antara kombinasi komponen gambaran radiologi (65%), kesesuaian lemah antara infark (64%), penyangatan sisterna basal dan fissura Sylvii (61%), hidrosefalus (59%), TB paru aktif (58%), perubahan CSS sisterna basal dan fissura Sylvii (58%), tuberkuloma (53%), dan tidak ada konkordansi antara abses TB (49%) dengan kriteria diagnosis TBM. Kesimpulan: Dari 7 komponen radiologi yang diperiksa, hanya abses TB yang tidak sesuai dengan kriteria diagnosis TBM. Kombinasi komponen gambaran radiologi, infark, penyangatan sisterna basal dan fissura Sylvii, hidrosefalus, TB paru aktif, perubahan CSS sisterna basal dan fissura Sylvii, dan tuberkuloma memiliki kesesuaian dengan kriteria diagnosis TBM.
Kata kunci: meningitis tuberkulosis; diagnosis; kriteria diagnosis; radiologi; CT; MRI


Background: Tuberculous meningitis (TBM) is the most severe extrapulmonary manifestation of tuberculosis (TB) with mortality and morbidity reaching 50%. HIV is a risk factor, and Indonesia is an endemic area for TB and HIV. The definitive diagnosis of TBM has low sensitivity and culture takes a long time. Radiological examination helps diagnose TBM through findings in the head, thorax, and other organs through chest radiography: active pulmonary TB, as well as CT/MRI of the head with contrast: hydrocephalus, enhancement of the basal cistern and fissure of Sylvii, tuberculoma, infarction, and basal cistern and fissure of Sylvii hyperdensity without contrast. Based on the consensus by Marais et al (2009), it was found that the diagnostic criteria for TBM including the criteria for clinical features, CSF features, radiological features of the brain, and extracranial TB findings. Currently in Indonesia and RSCM, there are no studies review the inter-test agreement of radiological images with diagnostic criteria in patients with suspected TBM. This study aims to optimize radiological examinations in patients with suspected TBM and determine the inter-test agreement of TBM diagnosis based on radiological examination with results based on TBM diagnostic criteria to help optimize clinical management. Methods: Inter-test agreement study, cross-sectional design. Consecutive sampling was performed on study patients with suspected TBM who met the inclusion criteria. An assessment of the presence of enhancement of the basal cistern and fissure of Sylvii, hydrocephalus, tuberculoma, infarction, changes in CSF of the basal cistern and fissure of Sylvii, and active pulmonary TB on CT or MRI examination of the head with intravenous contrast and chest radiography by the researcher and radiology supervisor. Then analysis with Kappa Cohen and concordance was performed. Results: In Kappa Cohen's analysis, there was a weak association between the combination of radiological components (0.29), infarction (0.27), enhancement of the basal cistern and fissure of Sylvii (0.22), minimal association between hydrocephalus (0.17), active pulmonary TB (0.16), changes in CSF of the basal cistern and fissure of Sylvii (0.15), and tuberculoma (0.08), as well as a negative association between TB abscess (-0.02) and the diagnostic criteria for TBM. In the Concordance analysis, there was moderate concordance between the combination of radiological features (65%), weak concordance between infarction (64%), enhancement of the basal cistern and fissure of Sylvii (61%), hydrocephalus (59%), active pulmonary TB (58%), changes in CSF of the basal cistern and fissure of Sylvii (58%), tuberculoma (53%), and there was no concordance between TB abscess (49%) and the diagnostic criteria for TBM. Conclusion: Of the 7 radiological components examined, only TB abscess did not meet the agreement with diagnostic criteria for TBM. The combination of radiological features, infarction, enhancement of the basal cistern and fissure of Sylvii, hydrocephalus, active pulmonary TB, changes in CSF of the basal cistern and fissure of Sylvii, and tuberculoma met the agreement with the diagnostic criteria for TBM.
Keyword: tuberculous meningitis; diagnosis; diagnostic criteria; CT; MRI