The many facets of disseminated parenchymal brain cysticercosis: A differential diagnosis with important therapeutic implications

Neurocysticercosis (NCC), the infection of the nervous system by the cystic larvae of Taenia solium, is a highly pleomorphic disease because of differences in the number and anatomical location of lesions, the viability of parasites, and the severity of the host immune response. Most patients with parenchymal brain NCC present with few lesions and a relatively benign clinical course, but massive forms of parenchymal NCC can carry a poor prognosis if not well recognized and inappropriately managed. We present the main presentations of massive parenchymal NCC and their differential characteristics.

Parasitic Infections of the Nervous System

PURPOSE OF REVIEW

This article reviews how parasites affect the human nervous system, with a focus on four parasitic infections of major public health importance worldwide, two caused by protozoa (malaria and toxoplasmosis) and two by helminths (neurocysticercosis and schistosomiasis).

RECENT FINDINGS

Parasitic infections in humans are common, and many can affect the central nervous system where they may survive unnoticed or may cause significant pathology that can even lead to the death of the host. Neuroparasitoses should be considered in the differential diagnosis of neurologic lesions, particularly in individuals from endemic regions or those with a history of travel to endemic regions.

SUMMARY

Cerebral malaria is a significant cause of mortality, particularly in African children, in whom infected red blood cells affect the cerebral vessels, causing severe encephalopathy. Neurocysticercosis is the most common cause of acquired epilepsy worldwide and has varied clinical presentations, depending on the number, size, and location of the parasites in the nervous system as well as on the host's inflammatory response. Toxoplasmosis is distributed worldwide, affecting a significant proportion of the population, and may reactivate in patients who are immunosuppressed, causing encephalitis and focal abscesses. Schistosomiasis causes granulomatous lesions in the brain or the spinal cord.

Tropical Neuroinfectious Diseases

PURPOSE OF REVIEW

This article discusses the assessment of the patient presenting with neurologic symptoms who has lived in or traveled through tropical or subtropical regions and reviews selected nervous system infections prevalent in the tropics and subtropics, with discussion of the epidemiology, clinical features, recommended diagnostic testing, and management.

RECENT FINDINGS

Increasing travel, emigration, and population growth all facilitate the global spread of tropical neurologic infections. Neurologists worldwide should be aware of the spectrum of neurologic manifestations as well as the most appropriate approach to diagnosis and management of these infections.

SUMMARY

Although many infectious tropical diseases affecting the nervous system are preventable or treatable, the burden of disease remains high, with significant socioeconomic costs associated with managing acute manifestations and chronic, often debilitating, neurologic sequelae. Tropical infections of the nervous system are often transmitted in regions where people live in poverty and where access to adequate health care is limited. As with most infections of the nervous system, timely access to proper treatment is of utmost importance, as delays are typically associated with worse outcome.

Clinical symptoms, diagnosis, and treatment of neurocysticercosis

The infection of the nervous system by the cystic larvae of Taenia solium (neurocysticercosis) is a frequent cause of seizure disorders. Neurocysticercosis is endemic or presumed to be endemic in many low-income countries. The lifecycle of the worm and the clinical manifestations of neurocysticercosis are well established, and CT and MRI have substantially improved knowledge of the disease course. Improvements in immunodiagnosis have further advanced comprehension of the pathophysiology of this disease. This knowledge has led to individualised treatment approaches that account for the involvement of parenchymal or extraparenchymal spaces, the number and form of parasites, and the extent of degeneration and associated inflammation. Clinical investigations are focused on development of effective treatments and reduction of side-effects induced by treatment, such as seizures, hydrocephalus, infarcts, and neuroinjury.

Neurocysticercosis

Known as a disease of swine in ancient civilizations, cysticercosis is currently considered the most common helminthic infection of the nervous system, and a leading cause of acquired epilepsy worldwide. The disease occurs when humans become intermediate hosts of the tapeworm Taenia solium by ingesting its eggs from contaminated food or, most often, directly from a Taenia carrier by the fecal-oral route. Once in the human intestine, Taenia eggs evolve to oncospheres that, in turn, cross the intestinal wall and lodge in human tissues - especially the nervous system - where cysticerci develop. The brain is a hostile environment in which parasites attempt to escape the immune surveillance while the host is trying to drive out the infection. In some cases, cysticerci are destroyed by this immunological attack, while in others, parasites may live unchanged for years. Cysticerci may be located in brain parenchyma, subarachnoid space, ventricular system, or spinal cord, causing a myriad of pathologic changes that are the main changes responsible for the clinical pleomorphism of neurocysticercosis. Seizures are the most common clinical manifestation of the disease, but some patients present with focal deficits, intracranial hypertension, or cognitive decline. With the exception of cystic lesions showing the scolex as an eccentric nodule, neuroimaging findings of neurocysticercosis are nonspecific and may be seen in other diseases of the nervous system. Likewise, immune diagnostic tests have been faced with problems related to poor sensitivity or specificity. Accurate diagnosis is possible after interpretation of clinical data together with findings of neuroimaging studies and results of immunologic tests, in a proper epidemiologic scenario. The introduction of cysticidal drugs has changed the prognosis of neurocysticercosis. Praziquantel and albendazole have been shown to reduce the burden of infection in the brain (as seen on neuroimaging studies) and to improve the clinical course of the disease in most patients. Further efforts should be directed towards eradicating this disease through the implementation of control programs for all the interrelated steps in the life cycle of T. solium, including human carriers of the adult tapeworm, infected pigs, and eggs in the environment.

[Paediatric neurocysticercosis: two case reports]

INTRODUCTION

Neurocysticercosis, caused by the larvae of Taenia solium, is the most common parasitic infection of the central nervous system in humans. Considered an endemic parasitosis in developing countries including Latin America, Asia and Africa while in Europa, the cases of neurocysticercosis are anecdotal.

CASE REPORTS

We report two cases of neurocysticercosis in children of non-Spanish origin who presented with seizures, with the initial diagnosis of brain tumors both were treated with surgery; later, to be the diagnosis of neurocisticercosis antiparasitic therapy was administered.

CONCLUSIONS

Neurocysticercosis can be a potential cause of epilepsy even in non-endemic countries. Some cases may be difficult to diagnose and they can be confused with other intracranial lesions. Clinicians should be aware of this condition given increasing incidence in Spain and neurocysticercosis should be always be considered in the differential diagnosis particularly in patients from Latin America and Africa.

Neurocysticercosis

Cysticercosis, an infection caused by the cystic larvae of the pork tapeworm Taenia solium, is one of the most frequent parasitic infections of the human nervous system (neurocysticercosis). It is endemic in most of Latin America, the sub-Saharan Africa, and vast parts of Asia, including the Indian subcontinent. It has also been increasingly diagnosed in developed countries because of migration of people from endemic zones and exposure in travelers. The life cycle involves the development of the adult tapeworm in the human small intestine (after ingesting infected pork with cysts) and larval infection in pig tissues (after ingesting human stools containing the eggs of the tapeworm). Humans get infected by the fecal-oral route, most often from a direct contact with an asymptomatic Taenia carrier. Most common clinical presentations are seizures (particularly late-onset seizures), chronic headaches, and intracranial hypertension. However, cysticerci can locate anywhere in the human nervous system, thus potentially causing almost any neurological syndrome and making clinical diagnosis a difficult task. Neuroimaging is the main diagnostic tool, and specific serology confirms the diagnosis and helps to define the diagnosis when images are unclear. Factors such as location (extraparenchymal versus intraparenchymal), number, size and evolutive stage of the parasites determine the clinical manifestations, therapeutic approach, and prognosis. Management includes symptomatic drugs (analgesics, antiepileptic drugs, anti-inflammatory agents) and in many cases cysticidal drugs, either albendazole or praziquantel. In recent years, efforts have focused on transmission control and potential elimination in endemic regions.

Neurocysticercosis in pregnancy: not just another headache

Infection with pork tapeworm, or Taenia solium, affects approximately 50 million people worldwide. The most important and potentially devastating form of the infestation, neurocysticercosis, occurs when the parasite invades the central nervous system. There has been a significant increase in the number of cases in the United States due to immigration from endemic areas. This case study of a pregnant woman in the 35th week of gestation exemplifies the serious consequences of this infection in pregnancy, and discusses an evidence-based approach to the diagnosis, treatment and eradication of this preventable disease.

[Pediatric neurocysticercosis]

Cysticercosis: parasitic disease which affects 3% of the population in Mexico. It is considered that there are more than 50 million infected people in the world, endemic in Mexico, Central and South America, Africa, Asia and India. It is considered the most important neurological infectious disease world-wide for its clinical manifestations. The causal agent in pigs and humans is the cysticercus of the Taenia solium, that can lodge in muscle, brain and ventricles. If pork meat contaminated with cysticercus is eaten, the tapeworm will live in the human intestine and create thousands of eggs that are excreted by the feces. When food contaminated with fecal matter is consumed by man or pig, the cisticercosis is disseminated in several parts of the organism, specially CNS. Man is the only host of the tapeworm and the pig is the only intermediary, reason why the prevalence of the teniasis-cisticercosis depends on this bond. It is diagnosed in endemic zones by the presence of convulsion crises, focal migraine, neurological symptoms, disorders of vision, endocraneal hypertension and CT scan with hypodense zones or cysts with a hyperdense ring. The antiparasitic treatment in children is controversial among pediatricians; it is suggested to use it only in the non calcified cystic phase and in cases associated with epilepsy. Few are the cases of hydrocephalic or intraventricular cysticercus that need surgical treatment.

Focal spinal intramedullary cysticercosis

Neurocysticercosis is the most common parasitic infestation of the CNS. Most authors have reported the incidence of spinal neurocysticercosis as only 1.5-3% of all cases, even in endemic areas. Spinal neurocysticercosis represents a distinct clinical entity that usually appears due to mass effect on the spinal cord. Most cases occur in the spinal subarachnoid space and cysticercosis in intramedullary location is extremely rare. The authors present a case of focal intramedullary spinal cysticercosis. The authors highlight the strategy for successful treatment of focal lesions in the intramedullary location.

[L-dopa sensitive Parkinsonism in neurocysticercosis]

INTRODUCTION

Neurocysticercosis (NC) is a chronic parasitary disease that may have different neurological manifestations, such as seizures, dementia or obstructive hydrocephalus. On rare occasions, pictures secondary to hydrocephalia may occur with Parkinsonian syndrome.

CASE REPORT

We present the case of a 29-year old woman with serologically confirmed NC and obstructive hydrocephalia secondary to a cyst in the IV ventricle. The patient required repeated ventricle-peritoneal shunt replacement because of valvular malfunction and obstructive hydrocephalia. She developed Parkinsonian's syndrome, which subsided after combined treatment with cysticidal drugs and L-dopa.

DISCUSSION

Parkinsonian syndrome is an atypical presentation in NC. In this case, the above-mentioned profile is found within the context of multiple valvular malfunctions who nature is reversible after appropriate treatment. It seems to be related with increases in intraventricular cerebrospinal fluid pressure. We can conclude that Parkinsonian syndromes may be one more expression of NC. This acquires greater importance according to its context, in addition to the limited presence of similar cases in our environment in the literature.

Spinal intramedullary cysticercosis of the conus medullaris

Neurocysticercosis is the most common central nervous system (CNS) parasitic disease worldwide, but spinal cysticercal infection is relatively rare, especially in the United States. Because of increased immigration to the United States from endemic areas, the incidence of neurocysticercosis has risen, especially in California, Texas, Arizona, and other southwestern states, but not in Wisconsin. Spinal intramedullary cysticercosis involving the conus medullaris is an uncommon clinical condition that can lead to irreversible neurological deficits if untreated. Rarely, Taenia solium, a cestode that causes neurocysticercosis, may produce spinal intramedullary lesion, which may mimic an intramedullary tumor. We report a case of thoracolumbar spinal intramedullary cysticercosis caused by Taenia solium. Spinal neurocysticercosis should be kept in mind in the differential diagnosis of intramedullary conus lesions even if the patient lives in Wisconsin.

[Epidemiological and clinical profile of neurocysticercosis patients assisted by the Hospital Universitário Regional de Maringá, Paraná, Brazil]

The aim of this study was to drawn an epidemiological and clinical profile of the neurocysticercosis (NCC) patients assisted by Hospital Universitário Regional de Maringá. A transversal, retrospective and descriptive study based on 6,100 records of the Neurology, Neuropediatry, Neurosurgery and Psychiatry clinics was done from January/1998 to December/2004. Of these, 48 were selected with diagnosis of NCC. The prevalence was greater in female (p<0.001), 31-60 years (43.7%), and urban zone (93.8%). The number of NCC cases overcame those notified to the Epidemic Surveillance in 1998, 1999, 2001, 2002 and 2004. The epilepsy due to NCC (CI=1.77;16.07; p=0.0024) was generalized and of late onset in 91.7% patients, being associated to headache in 37.5% ones. There was need of hospitalization in 22.9% of the patients (medium time of 3.91+/-3.35 days). It was concluded that the epidemiological and clinical profile observed is peculiar, displaying some common points with other Brazilian studies.

[Strokes caused by infection in the tropics]

INTRODUCTION

Almost three out of every four people in the world who suffer a fatal stroke live in developing countries. A number of different tropical diseases may appear in Europe in the coming years as a consequence of the demographic change that is being brought about by migratory flows. We review the main infectious causes of strokes in the tropics.

DEVELOPMENT

There are estimated to be 500 million cases of malaria every year. Cerebral malaria can cause cerebral oedema, diffuse or focal compromise of the subcortical white matter and cortical, cerebellar and pontine infarctions. Chagas disease is an independent risk factor for stroke in South America. At least 20 million people have the chronic form of Chagas disease. The main prognostic factors for Chagas-related stroke are the presence of apical aneurysms, arrhythmia and heart failure. Vascular complications of neurocysticercosis include transient ischemic attacks, ischemic strokes due to angiitis and intracranial haemorrhages. The frequency of cerebral infarction associated with neurocysticercosis varies between 2% and 12%. Gnathostomiasis is a cause of subarachnoid haemorrhage in south-east Asia. Other less common causes of stroke are viral haemorrhagic fevers due to arenavirus and flavivirus.

CONCLUSIONS

Several diseases that are endemic in the tropics can be responsible for up to 10% of the cases of strokes in adults.

[Diagnostic and therapeutic difficulties in neurocysticercosis: presentation of 6 cases and review of the literature]

INTRODUCTION

The incidence of neurocysticercosis (NCC) is increasing currently in developed countries due to the migration movements from endemic countries. Due to NCC polymorphism, treatment would be individualized in each case. Countries not used to this disease have to deal with.

GOALS

To set up diagnostic and therapeutic guidelines in all sorts of NCC and choose the correct treatment would be challenging.

PATIENTS AND METHODS

To perform a descriptive and retrospective analysis of six cases of NCC seen in the Neurosurgery Department of the Hospital Clinic de Barcelona from 1992 to 2000 (both included). We have performed a revision of the literature about diagnostic and therapeutic methods.

DISCUSSION

Definitive or probable diagnosis of NCC is based on clinical, imaging, immunological, and epidemiological criteria. In patients with inactive disease only symptomatic treatment is indicated. In active parenchymal forms there are not consensus if antiparasitic treatment is indicated. However, in extraparenchymal active disease aggressive treatment with antiparasitic agents and steroids is recommended. In cases of intracranial hypertension, neurological deficits or hydrocephalus surgery is the treatment of choice.

Advances in the diagnosis and management of neurocysticercosis

Neurocysticercosis is the most common cause of late-onset epilepsy in developing countries. The larval stage of Taenia solium is the causative agent of the disease. Recent advances in neuroimaging and serologic diagnostic techniques have led to increased recognition of its importance, but its pathogenesis is just beginning to be clarified. Experts now agree that the clinical manifestations, pathogenic mechanisms and optimal treatment vary with the number of parasites, their location and the degree of host inflammation. Symptomatic therapy (i.e., antiepileptic medications and, when indicated, surgery) is critically important but there are also important roles for antiparasitic and anti-inflammatory drugs. Neurocysticercosis is a potentially eradicable disease but this is probably unlikely to be achieved in the short term.

Treatment of intramedullary spinal cysticercosis: report of 2 cases and review of literature

BACKGROUND

NCC, Taenia solium involvement in the central nervous system, is one of the most common parasitic diseases. Spinal IMC is one of the rarest forms of NCC.

CASE DESCRIPTION

We report 2 cases (an 8-year-old child and a 35-year-old woman) of spinal IMC. Both cysts were dorsal in location. MRI was diagnostic in both cases. One case was treated surgically because of acute presentation. The other cyst healed with treatment with albendazole. Both patients had good clinical outcomes.

CONCLUSION

With medical management, IMC may take 1 year to resolve on MRI.

Treatment of neurocysticercosis: current status and future research needs

Here we put forward a roadmap that summarizes important questions that need to be answered to determine more effective and safer treatments. A key concept in management of neurocysticercosis is the understanding that infection and disease due to neurocysticercosis are variable and thus different clinical approaches and treatments are required. Despite recent advances, treatments remain either suboptimal or based on poorly controlled or anecdotal experience. A better understanding of basic pathophysiologic mechanisms including parasite survival and evolution, nature of the inflammatory response, and the genesis of seizures, epilepsy, and mechanisms of anthelmintic action should lead to improved therapies.

Neurocysticercosis: Current knowledge and advances

Neurocysticercosis is the most common cause of acquired seizures worldwide. Most cases of this larval stage infection of the pork tapeworm Taenia solium occur in the developing world, although increasing numbers of cases are being recognized in the United States, particularly among Hispanic immigrants. The ability of the pathogen to persist for years within the host is the subject of immunologic and biochemical investigation. The major presenting symptom is seizures, although symptoms of obstructive hydrocephalus occur if cysts are located near the ventricles or in the subarachnoid spaces. Diagnosis is dependent on clinical, radiologic, and serologic data. Therapy with antiparasitic agents, especially albendazole, is effective in large burden disease or disease within sensitive neuraxis sites (the ventricles, the subarachnoid spaces). When patients with radiologically enhancing disease are given cysticidal therapy, there appears to be a reduction in seizure recurrences. Surgery is indicated for disease in selected anatomic sites. Long-term prevention requires attention to pork husbandry and general sanitation, including the potential use of mass human chemotherapy and porcine vaccination.

[Neurocysticercosis: its aetiopathogenesis, clinical manifestations, diagnosis and treatment]

INTRODUCTION

Neurocysticercosis is an important cause of neurological disease in the world. Owing to massive emigration from endemic areas, its frequency has increased in developed countries. The present article reviews some of the specific features of this disease.

DEVELOPMENT

Cysticercosis occurs when man becomes the intermediary host of Taenia solium. The clinical presentation is pleomorphic and depends on the type, stage, location and number of lesions in the nervous system, as well as the host's response. For a correct diagnostic approach, an adequate interpretation of the clinical manifestations, neuro-imaging and immunodiagnosis conducted in an appropriate epidemiological context is required. The most frequent clinical manifestations are epilepsy, focal deficit, intra-cranial hypertension, and cognitive impairment. Imaging studies show pathognomic signs such as escolex and others that are not specific. The features of this parasitosis may be different in children. Partial crises and single parenchymatous cysts are the most frequent clinical and imaging manifestations of neurocysticercosis in children. Immunobiological tests in blood and cerebrospinal fluid have constraints in terms of sensitivity and specificity. Praziquantel and albendazole are the cyst-killing drugs that have proven to be most effective. Surgery plays an especially important role in hydrocephalus and ventricular cysts. Extra-parenchymatous neurocysticercosis has a poor prognosis.

CONCLUSION

Neurocysticercosis is a potentially eradicable disease. Health measures and the improvement of health systems can control transmission to man.

[Neurocysticercosis--pathogenesis and clinical aspects]

Neurocysticercosis is an infestation of the central nervous system with the larval cysts of the pork tapeworm (Taenia solium), when a man is paratenic host of the parasite. The infection results from ingestion of food or water contaminated with human feces containing the parasitic eggs. Much rarely, the infection is caused by autoinoculation, when the mature parasites are present in the small intestines, and reversed peristalsis gives rise to regurgitation of gravid proglottides (internal auto-infestation), or by ingestion of the eggs from one's own feces (external auto-infestation). The embryos (oncospheres) develop from the eggs, penetrating the small intestine mucosa and entering the circulation and subsequently different tissues and organs where cysticerci, small tissue larvae, are developed. Cysticerci have specific affinity for the central nervous system, eyes and striated muscles what is accounted for high concentration of glucose or glycogen in these organs. Neurocysticercosis is the most frequent parasitic disease of the central nervous system and the most common cause of convulsions and hydrocephalus in the adults in endemic regions, where the seroprevalence of disease is about 4% of population. Neurocysticercosis is classified into six clinical syndromes: asymptomatic, parenchymal, subarachnoid, intraventricular, spinal and ocular forms. Albendazole (benzimidazole) of 15 mg/kg/BW during 8-28 days or praziquantel (pyrazolone quinoline) of 50-60 mg/kg/BW during 15 days (or 100 mg/kg/BW only one day) are applied for treatment of neurocysticercosis.

[Neurocysticercosis in children: clinical study and follow-up of 112 patients]

INTRODUCTION

Neurocysticercosis (NC) is the infection of the central nervous system caused by the Taenia solium larva. It is related to a wide variety of clinical symptoms and pathological findings.

AIM

Clinical study, diagnosis, treatment and evolution of 112 patients with NC.

PATIENTS AND METHODS

112 patients with NC, between 1 and 14 years of age, were evaluated and followed from 18 months up to 13 years.

RESULTS

The most common clinical symptoms were epileptic seizures and signs of intracranial hypertension. The disease progressed as follows: active forms were seen in around 39% of the cases (viable cysts in 3% and transitional/granulomatous form in 36%), encephalitic form in 22% and inactive form (calcifications) in 39%. In the great majority of the cases, a treatment with anti-helmitic was not used. The control of the crises was positive in 86% of the cases -94% in the transitional forms, 93% in the inactive forms and 68% in the encephalitic form-. Recurrence of crises happened after suspension of the medication in 12,5% of the granulomatous form and in 11,2% of the inactive form. Neurological sequelae occurred only in the encephalitic form (12/25 patients).

CONCLUSIONS

Clinical findings and clinical evolution of neurocysticercosis in children is related to the evolutive form of the disease. The clinical evolution, including control of the crises and radiological control, is benign in the inactive and active forms, except in the encephalitic forms. The extraparenquimatous form is quite rare in the pediatric group.

[Neurocysticercosis: up-dating in diagnosis and treatment]

Cysticercosis occurs when humans become intermediate hosts of Taenia solium after ingesting its eggs. It is the most common helminthic infection of the nervous system, and is endemic in Latin America, Asia and Africa, as well as in industrialized nations with a high immigrant influx of people coming from endemic areas. Neurocysticercosis is a pleomorphic disease due to individual differences in the number and location of the parasites within the nervous system as well as to differences in the severity of the host's immune reaction against the parasite. Common clinical manifestations include epilepsy, focal neurological signs, intracranial hypertension, and cognitive decline. Diagnosis require proper interpretation of clinical, neuroimaging, and serologic data, in the correct epidemiological context. Neuroimaging studies show the parasites as well as the changes they induce in the nervous system. Tests developed to detect anticysticercal antibodies in serum or cerebrospinal fluid present problems inherent to lack of specificity or sensibility, and should not be used by themselves to confirm or exclude the diagnosis. Cysticidal drugs (albendazole and praziquantel) have improved the prognosis of this condition. However, some patients have torpid clinical courses despite therapy. Surgery plays an important role in the management of some forms of the disease, particularly hydrocephalus and intraventricular cysts.

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.

[Neurocysticercosis. An emergent disease]

Neurocysticerosis is an affection of the central nervous system by the larvae of the Taenia solium. Although its diagnosis in our country is exceptional, in recent years a notable increase in the number of cases diagnosed has been observed, due to the phenomenon of immigration from countries where the disease is endemic. The most frequent form of presentation of neurocysticercosis is seizures, followed by headache. To diagnose it we must evaluate the epidemiological data, the clinical record and confirm this through neuroimage and immunological studies. The treatment selected should be pharmacological, principally with albendazole, and surgery reserved for cases where the former fails. Hygienic measures and the treatment of patients with teniasis are of great importance. Neurocysticerosis has ceased to be an exceptional diagnosis and given the foreseeable increase of its incidence in our milieu, health professionals must understand this disease and include it at higher levels of the algorithms of differential diagnosis.

Syringohydromyelia associated to therapeutic procedures for severe forms of neurocysticercoses: case report

Syringohydromyelia is defined as a longitudinal dilatation of the central canal of the spinal cord with accumulated cerebrospinal fluid. This condition may cause neurologic deficits when the cavity enlarges and compresses the spinal cord. We present the case of a 33 years-old female with progressive paraparesis caused by syringohydromyelia. This patient underwent previously multiple clinical and surgical treatments for severe form of neurocysticercosis. Surgical decompression of the posterior fossa and syringostomy resolved the neurologic symptoms. The possibility of syringohydromyelia should be considered in the case of patients who have previously undergone surgical and clinical treatment for severe form of neurocysticercosis.

[Clinical study on the treatment of severe neurocysticercosis]

OBJECTIVE

To determine the therapeutic efficacy of albendazole combined with surgical intervention on intracranial hypertension in the treatment of severe neurocysticercosis.

METHODS

Seventy-four consecutive patients with severe neurocysticercosis were confirmed by neuroimaging techniques (CT and/or MRI) and ELISA for the detection of antibody to cysticerci of Taenia solium. The number of cysticerci in the brain ranged from 100 to 1160. All patients were treated with albendazole by dose-decreasing regimen. Initial tolerable dosage was defined by dose-decreasing progressively, depending on the total number of cysticerci; then the dose of albendazole was increased progressively, and ultimate dosage was 20 mg per kilogram of body weight daily. Albendazole was taken for 3-4 courses (10 days as a course). Drugs to reduce intracranial pressure were used in all patients during the treatment, including mannitol, corticosteroids and/or sodium escin. 67 patients with intracranial hypertension were treated with surgical treatment, including drainage of cerebral ventricle and/or decompression of temporal muscle. All patients received antiseizure medications to prevent the onset of seizures during the treatment.

RESULTS

The combination of albendazole and surgical intervention was curative in 69 of 74 patients with neurocysticercosis after a follow-up of an average 37.2 (19-52) months. CT and/or MRI examination demonstrated that the cysts had disappeared or become calcified. Only 1 case failed because there were 1160 cysts in the brain of the patient.

CONCLUSION

The combination of albendazole and surgical maneuvers to reduce intracranial pressure is a safe and effective method for treating severe neurocysticercosis.

Solitary cerebral cysticercus granuloma

Solitary cerebral cysticercus granuloma (SCCG) is one of the commonest causes of seizures in Indian patients. SCCG has been confused in the past with tuberculomas, but by applying a set of diagnostic criteria proposed by the author, they can be diagnosed accurately in the vast majority of patients. Patients with SCCG are managed effectively with antiepileptic drugs (AEDs). The role of cysticidal drugs in their management is controversial. SCCG resolves spontaneously at a variable rate and has a good seizure outcome, with >90% of patients remaining seizure free after discontinuation of AEDs.

[Current aspects in neurocysticercosis]

Neurocysticercoses with intraventricular cysts are presented in two operated patients. Cysticercosis, the most frequent parasitic infection of the central nervous system develops only sporadically in Hungary. In this paper epidemiology, different presenting forms, diagnosis, differential diagnosis and therapy are summarized. The purpose of the authors with this publication is to call attention to the diagnosis and the adequate treatment of neurocysticercosis imported from endemic areas.

Neurocysticercosis: regional status, epidemiology, impact and control measures in the Americas

The analysis of epidemiological data concerning human cysticercosis point to important advances in understanding the magnitude and distribution of this parasitic disease in Latin America, as well as the relationship of the elements that conform the life cycle of Taenia solium. The data indicate that the main risk factor for acquiring human neurocysticercosis and swine cysticercosis is the presence of the tapeworm carrier in the household. Therefore, several intervention measures for the control of cysticercosis have been evaluated: mass treatment in order to cure tapeworm carriers, health education towards understanding the risk factors, pig control by restraining them, experimental vaccination of pigs and treatment of swine cysticercosis. In this paper, we review the information obtained in these areas. We hope it will be useful in other endemic countries that wish to elaborate an action plan for the control and ultimate eradication of T. solium.

Neurocysticercosis--New Millennium, ancient disease and unending debate

A spurt of cases of Neurocysticercosis (NCC) at our department reopened the debate on whether to treat or not and spurred us on to review the available literature for a viable solution. Despite the disease having been around for centuries a cogent treatment plan eludes us even as other ancient scources have been successfully engaged. Neurocysticercosis presents a peculiar problem as it is an end-stage infection, accidental in man, with a benign natural course and would have merited considerably less attention, had it not chosen to infest the brain. These unique and characteristic features are the fundamental reasons why so many different treatment strategies are continuously proffered; many or none seem to work, depending on the viewpoint. And the target organs of this otherwise unglamorous tapeworm cyst--the brain, eye and spinal cord-ensure that there is always pressure, and temptation to treat rather than let it be, even if the weight of evidence is to the contrary. An overview of the history of the disease and the most recent happenings is presented here, in which these issues are reviewed with special attention to the debate on treatment. From the facts that emerge, an attempt has been made to present a workable plan that would help practicing pediatricians in treating most encountered cases till such time we hear the last word on the issue.

Parasitic worms of the central nervous system: an Australian perspective

The diagnosis and management of parasitic diseases of the central nervous system (CNS) is difficult, even for infectious diseases physicians and neurologists. Furthermore, few overviews of the spectrum of causative helminths and clinical syndromes have been published. In the present study, we review the seven most common parasitic diseases of the CNS: (i) cysticercosis, (ii) neuroschistosomiasis, (iii) paragonimiasis, (iv) angiostrongyliasis, (v) hydatid disease, (vi) sparganosis and (vii) gnathostomiasis. Major syndromes of parasitic disease of the CNS and their differential causes are discussed, including: (i) cystic lesions, (ii) enhancing granulomas (with and without creeping subcutaneous eruptions), (iii) eosinophilic meningoencephalitis and (iv) spinal cord disease. Specific risk factors that predispose to these infections are also discussed and particular attention is drawn to the situation in Australia.

Neurocysticercosis: nursing perspectives

Management of neurocysticercosis (NCC) is mostly by means of prevention and antihelminthic medications. We reviewed the role of medical and surgical intervention in patients with NCC lesions. We also identified two patients with isolated NCC lesions to determine whether they might be rendered seizure free through surgical removal of the lesion. The two patients, one male and one female, ages 21 and 43 years, respectively, presented with generalized seizures. Electroencephalograms showed focal slowing consistent with the site of the lesion and had failed antiepileptic drug therapy. Magnetic resonance imaging scans showed a distinct single-ring-enhanced lesion in each patient consistent with late-stage NCC. The patients underwent surgery with ultrasonagraphic guidance to remove the cysts. Surgery involved resection of the suspected calcified neurocystic lesion. Both patients have been seizure free since surgery. Patients with a single calcified neurocystic lesion may benefit from surgery for control of seizures. Prospective evaluations are needed to assess the timing of surgery in relation to the stage of the disease. Nurses play a significant role in the primary prevention of this disease and care throughout treatment.

Current consensus guidelines for treatment of neurocysticercosis

Taenia solium neurocysticercosis is a common cause of epileptic seizures and other neurological morbidity in most developing countries. It is also an increasingly common diagnosis in industrialized countries because of immigration from areas where it is endemic. Its clinical manifestations are highly variable and depend on the number, stage, and size of the lesions and the host's immune response. In part due to this variability, major discrepancies exist in the treatment of neurocysticercosis. A panel of experts in taeniasis/cysticercosis discussed the evidence on treatment of neurocysticercosis for each clinical presentation, and we present the panel's consensus and areas of disagreement. Overall, four general recommendations were made: (i) individualize therapeutic decisions, including whether to use antiparasitic drugs, based on the number, location, and viability of the parasites within the nervous system; (ii) actively manage growing cysticerci either with antiparasitic drugs or surgical excision; (iii) prioritize the management of intracranial hypertension secondary to neurocysticercosis before considering any other form of therapy; and (iv) manage seizures as done for seizures due to other causes of secondary seizures (remote symptomatic seizures) because they are due to an organic focus that has been present for a long time.

Review of neurocysticercosis

In the neurosurgical services in many developing countries, treatment of neurocysticercosis (NCC) accounts for greater than 10% of brain surgical procedures and approximately 15% of neurological consultations. In these areas brain cysticercosis is the leading cause of hydrocephalus in adults and the first cause of late-onset epilepsy. During the last two decades, successful medical treatment has been established. Additionally, neuroimaging and immunological studies have clearly defined the topography, pathophysiological mechanisms, and biological status of these lesions. Thus, selection of cases for medical or surgical treatment has improved; in a significant number of cases, both interventions are required. New therapies with either albendazole or praziquantel have respectively reduced to 8 days and to 1 day the course of anticysticidal therapy, which now is fast, effective, inexpensive, atoxic, and convenient, particularly in endemic areas where most patients belong to the lower socioeconomic groups. Additionally, the rational use of steroid agents facilitates the treatment of inflammation, a conspicuous accompaniment in cases of NCC. A major effort, however, is still required to eradicate this disease.