Neurocysticercosis and pure motor hemiparesis

Acute reversible monoparesis in multiple neurocysticercosis: A case report and review of literature

Focal neurological deficit like monoparesis due to cortical lesions is a rare entity. In spite of the common presentations like seizures and headaches in neurocysticercosis, occurrence of reversible monoparesis is an atypical phenomenon. Even in the absence of infarct or hemorrhages, manifestation of neural deficit due to compressive effect only is an interesting finding. And on top of that, reversible nature of the deficit in space occupying lesion is a rare occurrence in the existing literature. Here, we describe a known case of neurocysticercosis with reversible acute monoparesis secondary to multiple neurocysticercosis. The variations with which neurocysticercosis can present broaden our understanding in its pathophysiology and management protocol.

Suprasellar hamartoma and arachnoid cyst

OBJECTIVE

The differential diagnosis for suprasellar masses includes a variety of pathologies, ranging from stable and benign lesions to aggressive and malignant ones. We report a case of a suprasellar hamartoma associated with an arachnoid cyst and review the literature surrounding the topic.

CASE DESCRIPTION

A 32-year-old man who presented with headaches and nonspecific vision loss was found to have a cystic, calcified, and minimally contrast enhancing lesion of the suprasellar region. Intraoperative inspection revealed a discrete mass in the right side of suprasellar region that resembled normal brain completely enveloped by the basal arachnoid membranes including the membrane of Lillequist and was not connected to the brain. Fenestration and exploration of the cystic portion demonstrated a simple arachnoid cyst filled with what appeared to be cerebrospinal fluid. Given the adherence of the lesion to numerous perforating arteries arising from the posterior communicating artery, a biopsy with intraoperative confirmation was taken. Pathology was consistent with neuroglial tissue without evidence of neoplasia.

CONCLUSIONS

To our knowledge this is only the third case of an isolated suprasellar hamartoma described in the literature and the first of its kind to be associated with an arachnoid cyst.

Subarachnoid basal neurocysticercosis: a focus on the most severe form of the disease

Neurocysticercosis is an endemic disease in Latin America, Asia and Africa with growing occurrence in industrialized countries due to the increase in migration from low- and middle-income to high-income countries. The most severe clinical presentation is when the parasite is located in the subarachnoid space at the base of the brain (NCSAB). Aside from its clinical presentation, the severity of this form of the disease is due to the difficulties in diagnosis and treatment. Although NCSAB frequency is lower than that reported for the parenchymal location of the parasite, its clinical relevance must be emphasized. We provide a critical review of the central epidemiological, clinical, diagnostic and therapeutic features of this particular form of the disease, which is still associated with unacceptably high rates of morbidity and mortality.

Resolution of arterial stenosis in a patient with periarterial neurocysticercosis treated with oral prednisone

Neurocysticercosis is the most common parasitic infection of the central nervous system. Neurovascular complications have been recognized as a frequent complication, with up to 10% of strokes in endemic areas being secondary to neurocysticercosis. We report a case of acute transient left hemichorea in an 11-year-old boy with cerebral cysticercosis involving the right middle cerebral artery. Brain magnetic resonance imaging (MRI) revealed T(2)-weighted hyperintensity and gadolinium enhancement in the area surrounding the M1 segment of the right middle cerebral artery. Magnetic resonance angiography showed severe narrowing of the vessel at this site acutely. After treatment with a 1-month course of oral prednisone and initiation of aspirin, our patient had no recurrence of abnormal movements and follow-up magnetic resonance angiography and transcranial Doppler ultrasonography showed resolution of stenosis of the M1 segment.

Endoscopic removal of cisternal neurocysticercal cysts. Technical note

The authors report the use of neuroendoscopy for the treatment of cisternal neurocysticercosis. The utilization of the endoscope is meant to provide a safe and minimally invasive procedure for the removal of symptomatic cysts, minimizing morbidity and mortality relating to the natural history of the disease, as well as possibly avoiding a more extensive standard open craniotomy. A retrospective review of three cases of cisternal cysticercosis was performed. The presenting signs and symptoms, neuroimaging findings, endoscopic treatment, and outcomes are presented. The technical aspect of the endoscopic resection is described, with visual support provided by intraoperative video. Cerebrospinal fluid shunt placement was avoided in one patient in whom complete resection of the cyst was required. In one patient there were extensive interhemispheric and premesencephalic cisternal cysts, some of which could not be removed because of their multiplicity and extensive adhesions. Despite the intraoperative rupture of cysts, there were no cases of arachnoiditis or ventriculitis postoperatively. The minimally invasive endoscopic resection of cisternal cysticercosis is possible and effective in selected patients. Although the most appropriate treatment of cisternal cysticercosis remains a controversial issue, endoscopic resection should be considered as a primary treatment in symptomatic patients in cases that are amenable to endoscopic intervention.

Inflammatory aneurysm and neurocysticercosis: further evidence for a causal relationship? Case report

OBJECTIVE AND IMPORTANCE

Two cases of inflammatory aneurysms in patients with neurocysticercosis have been reported previously. Clinical and radiographic studies suggest a causal relationship.

CLINICAL PRESENTATION

A man with neurocysticercosis presented with an acute subarachnoid hemorrhage from a left middle cerebral artery aneurysm.

INTERVENTION

The patient underwent a craniotomy and clipping of his aneurysm. Diffuse inflammatory changes and multiple cysticercal cysts were found throughout the left sylvian fissure.

CONCLUSION

The patient had an uneventful recovery. Angiography suggested an inflammatory rather than a congenital aneurysm. Although rare, neurocysticercosis may induce aneurysm formation in the appropriate setting.

Uncommon presentations of neurocysticercosis

Neurocysticercosis commonly presents with seizures, raised intracranial tension and dementia. The unusual location of the cysts may result in uncommon manifestations mimicking a host of neurological disorders. Ten patients with neurocysticercosis with rare clinical presentations have been described in this series. These include dorsal midbrain syndrome, isolated bilateral ptosis, papillitis, cerebral hemorrhage, painful cervical radiculopathy, progressive swelling of arm, paraplegia due to intramedullary cyst, third ventricular cyst, dystonia and nominal aphasia masquerading as transient ischaemic attacks. The clinical details and possible mechanisms for these rare presentations are discussed.

Contralateral trigeminal neuralgia: a new clinical manifestation of neurocysticercosis: case report

In cysticercosis, the central nervous system is one of the most commonly affected sites; the clinical manifestations of this disease in the central nervous system can be very severe. The nature and intensity of the signs and symptoms depend on the location of the parasite; cysticeric situated in the cysternae may cause arachnoiditis and vasculitis, but the manifestations are rarely the result of their mass effect. We report the case of a 52-year-old woman with a racemose cysticercus in the left cerebellopontine angle, who presented with contralateral trigeminal neuralgia. The parasite was completely removed via a left suboccipital craniotomy. On the first postoperative day, the patient indicated that the pain had disappeared. The neuralgia was possibly caused by the distortion of the brain stem and the compression of the nerve against an arterial loop at the entry zone. This case demonstrates the advisability of obtaining imaging studies in all patients with trigeminal neuralgia before starting any treatment.

Subarachnoid neurocysticercosis with occlusion of the major intracranial arteries: case report

Cysticercosis is the most common parasitic disease affecting the central nervous system. Stroke is a recognized complication of neurocysticercosis, occurring in 2 to 12% of cases, mostly in the form of small lacunar infarcts. We report a case of hemiparesis and aphasia in a 51-year-old Hispanic woman, which was secondary to complete occlusion of the left internal carotid and bilateral anterior cerebral arteries. Magnetic resonance imaging demonstrated the presence of enhancing subarachnoid material surrounding these occluded cerebral arteries, providing antemortem, noninvasive documentation of the inflammatory meningeal cysticercotic reaction that was presumably responsible for the occlusive arteritis causing the cerebral infarction. This represents the third reported case of internal carotid artery occlusion and the first reported case of anterior cerebral artery occlusion secondary to neurocysticercosis.

Cerebral cysticercosis as a risk factor for stroke in young and middle-aged people

BACKGROUND AND PURPOSE

A probable association between cerebral cysticercosis and susceptibility to stroke, especially among young and middle-aged patients, has been reported. We examined the association between cerebral cysticercosis and stroke and the possible factors causing this association.

METHODS

In 169 stroke patients (75 males and 94 females) under 65 years of age admitted to our neurology department, we evaluated the following possible risk factors: arterial hypertension, diabetes, cardiac disease, hyperlipidemia, smoking, alcohol abuse, and cerebral cysticercosis. In 169 control patients under 65 years of age matched by sex and age, we evaluated the same possible risk factors for stroke.

RESULTS

In the univariate matched analyses, the frequencies of cerebral cysticercosis (p < 0.001), arterial hypertension (p < 0.001), cardiac disease (p < 0.001), hyperlipidemia (p < 0.05), and alcohol abuse (p = 0.05) were higher in the stroke patients than in the control patients. After controlling for possible confounding factors, we found that arterial hypertension (p < 0.001), cardiac disease (p < 0.001), and cerebral cysticercosis (p < 0.001) were independent risk factors for stroke.

CONCLUSIONS

Cerebral cysticercosis should be considered a risk factor for stroke in young and middle-aged individuals.

Cysticercosis and cerebrovascular disease: a review

Ischaemic cerebrovascular disease is a relatively common but under-recognised complication of neurocysticercosis. It is usually caused by inflammatory occlusion of the arteries at the base of the brain secondary to cysticercotic arachnoiditis. In most cases, the involved vessels are of small diameter and the neurological picture is limited to a lacunar syndrome secondary to a small cerebral infarct. However, large infarcts related to the occlusion of the middle cerebral artery or even the internal carotid artery have also been reported in this setting. CT and CSF examination usually support the cause-and-effect relationship between neurocysticercosis and the cerebral infarct by showing abnormalities compatible with cysticercotic arachnoiditis. An accurate diagnosis of this condition is important since early treatment with steroids is advised to ameliorate the subarachnoid inflammatory reaction which may cause recurrent cerebral infarcts.

Cerebral cysticercosis and stroke

BACKGROUND AND PURPOSE

In 1985 we initiated a protocol for examining the relationship between cerebral cysticercosis and stroke.

METHODS

In 420 stroke patients admitted to our department, our standard protocol of tests included blood tests, cardiac investigations, angiography, and immunologic cerebrospinal fluid measures. We assessed the following possible risk factors: arterial hypertension, diabetes, cardiopathy, high levels of cholesterol and triglycerides, smoking, alcohol abuse, and cerebral cysticercosis.

RESULTS

Of the 420 patients with stroke, we found cerebral cysticercosis in 31, five of whom were greater than 65 years of age and 26 of whom were less than or equal to 65 years. We determined that cerebral cysticercosis was the only possible risk factor for stroke in one of the five older patients and 15 of the 26 younger and middle-aged patients. Cortical infarctions were found in five of the 31 patients, with cerebral cysticercosis and lacunar infarctions in nine of these patients. One patient had intracystic hemorrhage. In 16 cases, neurological deficit was related to single or multiple cysts, colloids, granulomas, diffuse lesions, or pericystic edema. All patients with cerebral cysticercosis quickly recovered from their neurological deficit, except one who had a hemorrhagic cyst and died and another who remained disabled.

CONCLUSIONS

We established that, in patients with neurocysticercosis, occlusion of the small cortical or penetrating vessels at the base of the brain caused by arteriopathy was the most common mechanism of the stroke. Moreover, there is a probable association between cerebral cysticercosis and the susceptibility to stroke, particularly among young and middle-aged patients.

Neurocysticercosis presenting to the emergency department as a pure motor hemiparesis

We report the case of a 23-year-old male who presented to the emergency department (ED) with an isolated right-sided pure motor hemiparesis (PMH). An unenhanced computed tomography (CT scan) revealed a hypodensity in the area of the left parasagittal motor strip. The patient then experienced a Jacksonian type of seizure involving his right leg and was treated with intravenous phenytoin and dexamethasone. A second CT scan performed with contrast was thought to be consistent with a cerebral abscess with surrounding white matter edema. Surgical findings were consistent with neurocysticercosis. The patient was treated with praziquantel with nearly full recovery. Worldwide, cysticercosis is the most common CNS parasite. Because of immigration from endemic areas, cysticercosis has become more common in the United States. Patients with neurocysticercosis may arrive in the ED with a wide variety of unusual presentations. In this case, the PMH syndrome was caused by a solitary lesion in the motor strip. This report describes a case of PMH due to neurocysticercosis secondary to local mass affect alone. The literature of neurocysticercosis and PMH is reviewed and the pathogenesis, clinical presentation, and therapy are discussed.

MRI of thoracic cord in tropical spastic paraparesis

Images

Occlusion of the middle cerebral artery due to cysticercotic angiitis

Three patients with cysticercosis developed a cerebral infarct secondary to the occlusion of the middle cerebral artery or its major branches. Histopathologic examination revealed a large subarachnoid cysticercus surrounding the occluded arteries in two patients and diffuse thickening of the leptomeninges in one. Blood vessels around the parasite showed inflammatory changes that caused either occlusive endarteritis or thrombosis due to disruption of the endothelium. Cysticercosis should be considered as a cause of occlusion of the major intracranial vessels, particularly in young patients living in areas where this disease is endemic.

Pure motor stroke due to vertebral artery dissection

A 39-year-old man presented with a pure motor stroke 9 days after cervical chiropractic manipulation. Computerised tomographic scanning showed a pontine infarct. Cerebral angiography showed changes consistent with the diagnosis of bilateral vertebral artery dissection. It is postulated that the infarct resulted from artery-to-artery embolism.