The present study evaluated the role and timing of invasive procedure like open or stereotactic biopsy in patients of Chronic meningitis.

Chronic meningitis remains a challenge for the treating Neurophysician and requires detailed work-up including Imaging (CT, MRI Brain, and at times FDG-PET), Serological markers, and exhaustive Cerebrospinal fluid (CSF) to reach a correct diagnosis. Isolation of the causative organism is usually possible in less than half of the patients due to paucibacillary conditions. Hence the treatment is empirically started based on history, local epidemiology, imaging findings and CSF parameters in the absence of isolation of organisms. The outcome of the disease depends on the correct diagnosis, timely treatment, and the stage of the disease.

We describe here a series of 5 patients who were empirically treated as cases of Tuberculous meningitis, based on history, examination, epidemiology, Imaging findings (Enhancing basal exudates, hydrocephalus, subcortical infarcts, ring-enhancing lesions, spinal arachnoiditis, etc. in varying combinations). As most of these patients kept on worsening despite being on Anti-tubercular therapy (ATT), biopsies were attempted from relatively difficult-to-access brain and spinal lesions. 

In patients suffering from Chronic meningitis, all attempts should be made to isolate the causative organism. Repeated CSF examination in large volumes is usually helpful in confirming the diagnosis. However, in some cases where the disease is worsening on empirical therapy, tissue diagnosis should be attempted. Certain radiological findings on MRI like the presence of hemorrhages in susceptibility-weighted imaging or the presence of skull base osteomyelitis should alert the treating physician towards a fungal etiology.