Quantitative ASL Perfusion and Vessel Wall MRI in Tuberculous Meningitis: A Pre- and Post-Treatment Study

<b>Background:</b> Tuberculous meningitis (TBM) is a severe central nervous system infection that can lead to cerebral vasculitis and infarction. This study aimed to evaluate changes in cerebral perfusion and vasculitis on magnetic resonance imaging (MRI) before and after anti-tuberculosis treatment, focusing on both infarcted and non-infarcted brain regions and comparing them with age-matched controls. <b>Methods:</b> Quantitative arterial spin labeling (ASL) perfusion and black-blood vessel wall MRI were performed at diagnosis and after 3-6 months of treatment in TBM patients and healthy controls. Regions of interest included infarcted areas, the contralateral normal brain, and TBM-affected regions without infarction. Cerebral blood flow (CBF), perfusion grading, and vasculitis were assessed and correlated with clinical stage and disease severity. <b>Results:</b> In total, 73 TBM patients and 26 controls were included. Among the patients, 26 (35.6%) had acute infarctions, mainly in the basal ganglia and corona radiata, and 65 (89.0%) exhibited vasculitis predominantly involving anterior circulation. Pretreatment MRI showed significantly reduced CBF in infarcted regions compared with contralateral brain and controls (<i>p</i> < 0.05), and both contralateral and non-infarcted TBM regions also showed lower CBF than controls (<i>p</i> < 0.05). After treatment, CBF increased significantly in non-infarcted regions (<i>p</i> < 0.05), and post-treatment perfusion grade correlated with TBM stage and vasculitis severity. <b>Conclusions:</b> TBM-related infarcts demonstrated marked hypoperfusion, while non-infarcted regions exhibited reversible ischemic changes. ASL and vessel wall imaging can quantitatively monitor treatment response and vascular inflammation, as well as predict late infarction in TBM patients.