Neurocysticercosis: A Neurosurgical Perspective

Optical Coherence Tomography Features of Ocular Cysticercosis: A Review of Literature With Observer Variation

Ocular cysticercosis is a sparsely reported condition, requiring urgent management. The gold standard for diagnosis is an in toto extraction of the cyst with subsequent histopathology. The procedure can be demanding in contrast to the frequently adopted practice of in vivo cyst lysis. The latter, however, obviates a conventional biopsy. We reviewed published optical coherence tomography (OCT) images of ocular cysticercosis for their suitability to surrogate a conventional biopsy and identified commonly reported features. We also used triple masking and ascertained the observer agreement on identification of these features. We found that the features of the parasite are much more clearly discernible as compared with features of the involved ocular tissue itself. The hyperreflective cyst wall and scolex and the hyporeflective cyst cavity had the highest frequency and observer agreement among all the analyzed features, suggesting their use for diagnosis. We could match many of the OCT features with the previously reported histopathological findings, supporting the role of OCT as a diagnostic adjunct and a substitute for conventional biopsy. Conversely, features of the ocular tissue could be judged poorly with low observer agreement, suggesting poor prognostic ability of OCT. [Ophthalmic Surg Lasers Imaging Retina 2022;53:446-454.].

Stereotactic surgery for neurocysticercosis of the 4th ventricle: illustrative cases

BACKGROUND

Neurocysticercosis, caused by the larval stage of Taenia solium, affects the cerebral ventricles in 20–30% of cases and may lead to hydrocephalus and other neurological morbidity. Conventional treatment for cysts in the 4th ventricle includes open surgery (suboccipital approach) and neuroendoscopy, with the latter being the option of choice. Stereotactic surgery, minimally invasive, offers a good alternative for this type of deep lesion.

OBSERVATIONS

The authors report the cases of two women, 30 and 45 years old, who presented with headache, dizziness, and ataxia and were diagnosed with 4th ventricle cysticercosis. Magnetic resonance imaging (MRI) revealed dilated 4th ventricles (approximately 2.5 cm in both cases, with cystic images inside the ventricular cavity). Both patients were treated with stereotactic surgery via a suboccipital transcerebellar approach. Cyst material was extracted, and the diagnosis was confirmed by pathological examination. The surgeries had no complications and resulted in clinical improvement. Control MRI scans showed reduction of the volume of the ventricle without residual cysts.

LESSONS

Minimally invasive stereotactic surgery provided a safe alternative for 4th ventricle neurocysticercosis cysts, with more benefits than risks in comparison with conventional techniques.

Fourth ventricle neurocysticercosis: A case report

Background:

Neurocysticercosis (NCC) is the most common helminthic disease of the nervous system in humans and it is caused by the larvae of the pork tapeworm, Taenia solium. We present a case of microsurgical removal of a fourth ventricle NCC cyst combined with an endoscopic third ventriculostomy (ETV) to treat hydrocephalus.

Case Description:

A 36-year-old woman presented to the emergency room with headache and decreased visual acuity over the last 4 months. A brain magnetic resonance imaging showed obstructive hydrocephalus apparently correlated to a mobile, cystic lesion of the fourth ventricle. In the same operative time, an ETV and a suboccipital craniotomy were performed in order to remove the lesion and to treat the hydrocephalus. The cyst was completely removed and pathologically identified as a T. solium cyst. The early postoperative course was uneventful and she was discharged asymptomatic and off anthelmintic medication. Five weeks later, the patient returned with hydrocephalus recurrence and was successfully retreated with an ETV. At 5-month follow-up, she remains asymptomatic and has no evidence of persistent disease or hydrocephalus recurrence.

Conclusion:

Intraventricular neurocysticercosis is, typically, a surgical disease. For cysts located on the fourth ventricle, a suboccipital craniotomy and a telovelar approach remains a valid option. Cyst removal does not necessarily resolve the hydrocephalus problem. ETV offers an option to the classic shunt placement approach and was shown to be effective even on hydrocephalus recurrence.

Endoscopic Management of Fourth Ventricle Neurocysticercosis: Description of the New Technique in a Case Series of 5 Cases and Review of the Literature

BACKGROUND

Around 7%-33% of cases of neurocysticercosis (NCC) have intraventricular involvement, and the fourth ventricle is the most frequent site. Medical management and various surgical approaches have been described for treating this disease. The objective of this study was to describe technical modification for endoscopic fourth ventricular NCC removal in a series of 5 cases.

METHODS

In this study (January 1, 2016, to December 31, 2017), all cases of fourth ventricular NCC which were treated with a special technique (endoscopic transcortical transforaminal transaqueductal approach) using a rigid endoscope system and 6-French infant feeding tube (IFT) were included in the study. The IFT was passed through the main channel, the cyst was engaged at the tip by applying gentle suction with a 20 cm³ syringe, and the cyst was removed along with the whole endoscopic assembly. Patient's clinical, radiologic, and follow-up data were retrieved from the department database records.

RESULTS

Five patients (3 men, 2 women; mean age, 20 years; range, 11-27 years) were enrolled. All patients had features of raised intracranial pressure. Two patients also had drop attacks, and one presented with altered sensorium and one had upgaze palsy. Duration of symptoms ranged from 3 months to 3 years. All patients had isolated fourth ventricular NCC with obstructive hydrocephalus. Complete removal of the neurocysticercal cyst could be performed in all patients without any injury to the periaqueductal region or fornix. There was no intraoperative rupture of the neurocysticercal cyst. On follow-up (range, 12-28 months; mean, 19.4 months), all patients had relief of symptoms and imaging showed no cyst and hydrocephalus.

CONCLUSIONS

We conclude that our endoscopic approach is safe, simple, cost-effective, and allows minimally invasive removal of the fourth ventricle cyst and treatment of hydrocephalus without any morbidity.

Spinal racemose cysticercosis: case report and review

Cysticercosis is a common helminthic infection worldwide, endemic in Central and South America, sub-Saharan Africa, and Southeast Asia. Neurocysticercosis typically involves brain parenchyma, subarachnoid space, and the ventricular system. Although the spinal cord is frequently involved in patients with parenchymal neurocysticercosis, isolated spinal involvement is rare, occurring in only 1-3% of patients. We report a case of racemose spinal neurocysticercosis with brain parenchyma involvement in a 49-year-old Mexican man, who presented with unsteady gait and bilateral arm numbness and weakness. Magnetic resonance imaging revealed multiseptated cystic lesions in the upper cervical spinal canal and nonenhancing intradural extramedullary cystic lesions in the thoracic spine. The patient underwent sub-occipital craniectomy with decompression, followed by a course of steroids and albendazole. Pathology confirmed the diagnosis of neurocysticercosis, and the patient's symptoms resolved after treatment. We include discussion on the symptoms, diagnosis, and treatment of neurocysticercosis with a focus on the spinal form.

Intramedullary spinal neurocysticercosis presenting as brown-sequard syndrome

Cysticercosis is an emerging disease in the United States. Neurocysticercosis may rarely cause disease within the spinal cord, but the occurrence of such pathology can produce debilitating symptoms for patients. We present the second report in the literature of intramedullary spinal neurocysticercosis presenting with a Brown-Sequard syndrome.

Neurocysticercosis: fireflies in the central nervous system

Neurocysticercosis (NCC) is caused by cysticerci spreading to spinal or brain tissue. NCC causes headaches, seizures, and focal neurological deficits. NCC is one of the main causes of epilepsy worldwide. NCC can cause death if it is not adequately treated. NCC is preventable through education of proper handwashing techniques proper food handling, and separation of human and pig living quarters (CDC 1998). The International League Against Epilepsy (ILAE), the World Health Organization (WHO), and other international health organizations are attempting to rid the world of NCC through education. Cysticerci create cavities in the brain and other body tissue where their tiny bodies grow sometimes into tapeworms two to seven meters in length and can live up to 25 years in the human body. On magnetic resonance imaging (MRI) wormholes appear Often times, if best practice is followed, the patient's entire body is scanned and more craters appear. Some authors have stated that cysticerci on a computed topography (CT) scan are similar to a starry sky or fireflies (Kapur et al. 2007).

Transventricular, transaqueductal scope-in-scope endoscopic excision of fourth ventricular neurocysticercosis: a series of 13 cases and a review

OBJECT

Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system worldwide. In patients presenting with acute hydrocephalus due to intraventricular NCC, surgery is the only option. Still, there is no consensus regarding the optimal surgical strategy, although neuroendoscopic excision is a promising method. However, the literature regarding the use of this modality in fourth ventricular NCC is scarce. The authors describe a series of patients with fourth ventricular NCC treated endoscopically.

METHODS

The clinical records of 13 patients with fourth ventricular NCC who had presented with hydrocephalus were retrospectively analyzed. A fourth ventricular cyst was completely excised in all patients by using a transventricular, transaqueductal "scope-in-scope" endoscopic technique. Twelve endoscopic third ventriculostomies and 1 septostomy had been performed.

RESULTS

Shunt placement was avoided in all patients. There were minimal peri- and postoperative complications. The mean duration of follow-up was 22.3 months (range 3-41 months). All patients had an improved clinical outcome. Follow-up neuroimaging revealed no residual lesion and a decreased ventricle size in all patients.

CONCLUSIONS

The present series of patients with fourth ventricular NCC is the largest in the existing English-language medical literature. Endoscopic fourth ventricular cysticercal cyst excision along with internal cerebrospinal fluid diversion via endoscopic third ventriculostomy is an effective alternative to open microneurosurgical procedures and avoids shunt placement and its related complications.

ENDOSCOPIC TRANSAQUEDUCTAL REMOVAL OF FOURTH VENTRICULAR NEUROCYSTICERCOSIS WITH AN ANGIOGRAPHIC CATHETER

OBJECTIVE

Fourth ventricular neurocysticercosis (FVNCC) usually presents with obstructive hydrocephalus. Available treatment options are medical, external cerebrospinal fluid diversion, microsurgical, or endoscopic removal alone or in combination. We present our experience of transaqueductal removal of FVNCC by angiographic catheter with endoscopic third ventriculostomy with a rigid endoscope.

METHODS

Ten patients (five male and five female patients; age range, 12-45 yr; mean, 23.2 years) with FVNCC with obstructive hydrocephalus underwent endoscopic removal along with endoscopic third ventriculostomy in a single sitting, through a frontal precoronal burr hole. Diagnosis was established on imaging and confirmed on histology in all of the cases. The Gaab Universal Endoscope System along with 4-mm, 30-degree rigid telescopes was used to enter the third ventricle, and a cut length of angiographic catheter was negotiated through the aqueduct for removal of FVNCC.

RESULTS

Removal of the cyst was performed in all cases. A 30-degree rigid telescope provided excellent image quality, with the ability to address intra-FVNCC through the dilated aqueduct with a curved-tip catheter. None of these patients required any further surgery. There were no significant operative or postoperative complications in any of the cases. All of the patients were asymptomatic, with an average follow-up of 18 months.

CONCLUSION

Transaqueductal removal of an intra-fourth ventricular cyst along with endoscopic third ventriculostomy with a rigid endoscope and catheter is an effective treatment and obviates the need for posterior cranial fossa exploration.

Neuro-endoscopic management of intraventricular neurocysticercosis (NCC)

OBJECTIVE

Various approaches including endoscopy have been used for the treatment of intraventricular and cisternal NCC. We present our technique of Neuro-endoscopic management of intraventricular NCC.

METHODS

Twenty-one cases, 13 females and 8 males (age range 12-50 years; mean, 25.7 years), of intraventricular NCC [lateral (n = 6), third (n = 6), fourth (n = 10) ventricles including a patient with both lateral and third ventricular cysts] producing obstructive hydrocephalus formed the group of study. Gaab Universal Endoscope System along with 4 mm 0 degrees and 30 degrees rigid telescopes were used through a frontal burr-hole for removal of intraventricular including intra-fourth ventricular (n = 10) NCC. Endoscopic third ventriculostomy (ETV) was done for internal cerebrospinal fluid (CSF) diversion. Average follow up was 18 months.

RESULTS

Complete (n = 18) or partial (n = 2) removal of NCC was done in 20 patients, while a cyst located at foramen of Monro slipped and migrated to occipital or temporal horn in 1 patient. Thirty-degree 4-mm rigid telescope provided excellent image quality with ability to address even intra-fourth ventricular NCC through the dilated aqueduct using a curved tip catheter. No patient required further surgery for their hydrocephalus. There was no operative complication and post-operative ventriculitis was not seen in any case despite partial removal of NCC.

CONCLUSION

Neuro-endoscopic surgery is an effective treatment modality for patients with intraventricular NCC. It effectively restores CSF flow and is capable of removing cysts completely or partially from accessible locations causing mass effect. Partial removal or rupture of the cyst does not affect the clinical outcome of the patients.

Neurocysticercosis

Since international travel has become widespread, clinicians increasingly have been confronted with the diagnosis of symptomatic and incidental neurocysticercosis. The difficulty with managing this disease lies in its varied clinical presentations. The treatment of neurocysticercosis depends upon anatomic locations, stages of cysts, and overall cyst burden. Despite recent clinical and laboratory advances, experts are divided on many key management questions. This article reviews the pathophysiology and experimental data underlying treatment recommendations for this emerging and complex condition.

Neurocysticercosis: updated concepts about an old disease

Neurocysticercosis, the infection of the human brain by the larvae of Taenia solium, is a major cause of acquired epilepsy in most low-income countries. Cases of neurocysticercosis are becoming more common in high-income countries because of increased migration and travel. Diagnosis by neuroimaging and serological assessment has greatly improved over the past decade, and the natural progression of the disease and response to antiparasitic drugs is now much better understood. Neurocysticercosis is potentially eradicable, and control interventions are underway to eliminate this infection. Meanwhile, updated information on diagnosis and management of neurocysticercosis is required, especially for clinicians who are unfamiliar with its wide array of clinical presentations.