The meninges which are thin layers of protective membranes (3 in number, named from outside to inside, (i) the durra mater, (ii) the arachnoid mater and (iii) the pie mater) covering the brain may also become involved as a result of tuberculosis, and the disease is called tuberculous meningitis. In this case, the infection spreads from the brain to the meninges. Initially, a slow-growing tuberculous lesion called 'tuberculoma' develops in the brain, adjacent to the meninges, which ruptures in the subarachnoid space, i.e., the space between the second and third layer/meninx, causing infection of the meninges, leading to the signs and symptoms of tuberculous meningitis.

It was sometimes thought that there is a true entry of the tubercle bacilli from this 'tuberculoma' into the subarachnoid space. The author has discussed this aspect of the etiology of tuberculous meningitis  with Dr. William Boyd (Canada), a renowned pathologist, who has also written "Text Book of Pathology"  as well as "Pathology for the Physician".  In one of his communications to the author, while finally agreeing  that there is indeed a rupture of tuberculoma into the subarachnoid space, he wrote, "Needless to say, I was most interested in your case of focal epilepsy followed by tuberculous meningitis. It seems to me that your idea of a tuberculoma rupturing and discharging bacilli into the subarachnoid space is the most reasonable one". In one case discussed with Dr. Boyd,  the patient developed focal epilepsy as a result of tuberculoma in the brain. 

An early diagnosis and treatment of tuberculous meningitis is most important in order to save the patient from various neurological deficits. It should be treated as a medical emergency. A delay in treatment could result in permanent disabilities. Initially, the patient gets vague symptoms like malaise, loss of appetite, a vague headache, irritability, and soon he gets the so-called symptoms and signs of meningial irritation, as a result of the tuberculous infection of the meninges, like a persistent headache, vomiting, neck rigidity / stiffness, etc.  Stiffness of the neck is a valuable sign of this disease, and the rigidity of the neck gives the clinical clue to the diagnosis of tuberculous meningitis. Another important sign is that the patient cannot extend the leg after the thigh has been flexed, or brought close to the abdomen (called Kernig's sign).  The signs and symptoms of an acute meningeal infection are best recognized by the physician, either in the emergency room or by the consulting neurologist.

It is important to recognize all the early signs and symptoms of tuberculous meningitis before the disease progresses. All the relevant diagnostic tests must be carried out to locate the lesion of tuberculosis in other parts of the body, especially in the lungs. An examination of the cerebrospinal fluid (CSF), as well as the computed tomographic (CT) scanning of the head, are required for the diagnosis of tuberculous meningitis. Once diagnosed, the patient should be immediately placed on appropriate antituberculosis treatment for an extended period of time, so as to eradicate the infection of tuberculosis from the brain.