A case-based review on the neuroendoscopic management of intraventricular and subarachnoid basal neurocysticercosis

OBJECTIVE

Extraparenchymal localization of neurocysticercosis (NCC) is rare in non-endemic areas. A case of mixed (intraventricular, IV, and subarachnoid basal, SAB) NCC was surgically treated using the neuroendoscope and a systematic review of the literature was performed with the aim to analyze the use of this instrument in the management of the extraparenchymal forms of the parasitic disease.

MATERIALS AND METHODS

Medline and Embase databases were searched for studies where the neuroendoscope was used for the management of IV/SAB NCC cysts, either for the cerebrospinal fluid diversion or cyst removal. Cyst location, complete removal, cyst breakage during removal, intraoperative and postoperative complications, administration of antihelmintic therapy, outcome and follow-up period were extracted from the articles.

RESULTS

281 patients were treated by means of the neuroendoscope. 254 patients who were described in retrospective cohort studies, came all from endemic areas, with no significant difference between sexes. Mean age at surgery was 30.7 years. Of all cysts reported in retrospective studies, 37.9% were located in the fourth ventricle. An attempt of cyst removal was described in the 84.6% of cases and an endoscopic third ventriculostomy was performed in another 76.4%. A small number of complications were reported intraoperatively (9.1%) obtaining, but a good recovery was achieved at follow-up. Only 17 ventriculoperitoneal shunts were placed after the first procedure, defining a low risk of postoperative hydrocephalus even in case of partial cyst removal.

CONCLUSION

Neuroendoscopic removal of an extraparenchymal NCC cyst is a safe procedure that should be preferred for lateral and third ventricle localization and, in a specialized centre, even for a localization in the fourth ventricle if feasible. It is also efficient because of the possibility of performing an internal CSF diversion concomitantly to cyst removal, avoiding the complication registered with VPS. The need for cysticidal treatment after surgery should be addressed in a prospective study.

Postsurgical Outcomes of Mesial Temporal Lobe Epilepsy due to Hippocampal Sclerosis Associated with Calcified Neurocysticercosis

The aim of this study was to analyze postsurgical outcomes for individuals with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) who underwent anterior temporal lobectomy, based on the presence of calcified neurocysticercosis (cNCC). A retrospective cross-sectional study was conducted on 89 patients with MTLE-HS who underwent anterior temporal lobectomy between January 2012 and December 2020 at a basic epilepsy surgery center located in Lima, Peru. We collected sociodemographic, clinical, and diagnostic information. The postsurgical results were analyzed using bivariate analysis according to the Engel classification. We included 89 individuals with a median age of 28 years (interquartile range [IQR]: 24-37), and more than half (55.1%) were male. Seventeen (19.1%) were diagnosed with cNCC. A greater number of patients with cNCC had lived in rural areas of Peru during their early life compared with those without cNCC (12 [70.6%] versus 26 [36.1%]; P = 0.010). Patients with cNCC exhibited a greater median frequency of focal to bilateral tonic-clonic seizures per month (1 [IQR: 0-2] versus 0 [0-0.5]; P = 0.009). Conversely, a lower proportion of patients with cNCC reported a history of an initial precipitating injury in comparison to the group without cNCC (4 [23.5%] versus 42 [58.3%]; P = 0.014). At the 1-year follow-up, most patients (82.4%) with cNCC were categorized as Engel IA. Similarly, at the 2-year follow-up, nine (75.0%) were classified as Engel IA. Our findings suggest that most patients diagnosed with cNCC exhibit favorable postsurgical outcomes, comparable to those without cNCC. Additionally, it can be postulated that cNCC may play a role as an initial precipitating injury.

Is Antihelminthics Necessary in Postoperative Treatment of Intraventricular Neurocysticercosis? A Systematic Review

OBJECTIVE

Patients with intraventricular neurocysticercosis (IVNCC) may require cerebrospinal fluid diversion surgery for late-onset hydrocephalus in the postsurgical period. Controversy exists regarding cysticidal treatment. Our main objective was to compare surgically treated cases of IVNCC that received postoperative anthelmintics with those that did not regard the incidence and treatment of late-onset hydrocephalus.

METHODS

We searched the Medline database and extracted the following data: age, gender, stage of development of cysticercosis, type of operation, frequency of delayed hydrocephalus, cerebrospinal fluid diversion surgery, outcome, and follow-up.

RESULTS

We analyzed 130 articles on intraventricular cysticercosis and identified 117 cases of isolated IVNCC and 314 patients in the case-control series who met inclusion criteria. There was no significant difference in postoperative delayed hydrocephalus between isolated IVNCC and case-control study groups. Children under the age of 16 received anthelmintic drugs more frequently during the postoperative period. Statistical relevance was observed in all patient groups regarding the application of steroids in favor of cysticidal therapy Endoscopy was a better option than craniotomy for cases of isolated IVNCC and case-control studies. Other variables were not relevant.

CONCLUSIONS

Patients who received antihelminths did not show a statistically significant reduction in delayed hydrocephalus compared to individuals who did not receive after surgical resection of the parasite. Corticosteroid therapy prevailed in people who have been treated with anthelmintics. Children under the age of 16 were administered anthelmintic drugs more frequently during the postoperative period. Endoscopy was the preferred method for all groups, but some patients with cysts in the fourth ventricle required a craniotomy.

Neurocysticercosis and hydrocephalus: the value of ventriculoperitoneal shunting in its management

BACKGROUND

Hydrocephalus is the main complication of extraparenchymal neurocysticercosis (EP-NC). Its symptomatic management relies mainly on the placement of a ventriculoperitoneal shunt (VPS). Previous studies have shown that this surgical procedure is associated with a poor prognosis, but current information is lacking.

METHODS

We included 108 patients with a definitive diagnosis of EP-NC and hydrocephalus requiring VPS placement. We evaluated their demographic, clinical, and inflammatory characteristics, as well as the frequency of complications related to VPS placement.

RESULTS

Hydrocephalus was present at the time of NC diagnosis in 79.6% of patients. VPS dysfunction occurred in 48 patients (44.4%), mainly within the first year after placement (66.7%). The dysfunctions were not associated with the location of the cyst, the inflammatory characteristics of the cerebrospinal fluid or the administration of cysticidal treatment. They were significantly more frequent in patients in whom the decision to place a VPS was made in the emergency department. Two years after VPS, patients' Karnofsky score averaged 84.6±15 and only one patient died of a cause directly related to VPS.

CONCLUSIONS

This study confirmed the utility of VPS and showed a significant improvement in the prognosis of patients requiring VPS compared with previous studies.

Isolated Intraventricular Neurocysticercosis: Atypical Presentation of a Colloid Cyst

Neurocysticercosis is a condition characterized by the presence of Taenia solium (larval stage: Cysticercus cellulosae) in the brain and is classified as a tropical disease. Although it was previously uncommon in Europe, the number of cases has been increasing over the past decade. In this report, we present a case of a patient who was admitted with symptoms of raised intracranial pressure and biventricular hydrocephalus, without evidence of infection. Imaging studies revealed the presence of an atypical colloid cyst, which was subsequently removed using a neurosurgical endoscopic approach. Anatomopathologic analysis confirmed the presence of a C. cellulosae larva. It is crucial not to overlook or misdiagnose isolated intraventricular neurocysticercosis because it can lead to complications such as delayed diagnosis and dissemination of the cyst.

Intraventricular migration of fourth ventricular neurocysticercosis: an unusual complication during endoscopic surgery

A boy in his middle childhood presented with intermittent episodes of headache with vomiting for 6 months. Plain CT of the head and MRI of the brain revealed fourth ventricular cysticercal cyst with acute obstructive hydrocephalus. Endoscopic excision of the cyst was done along with endoscopic third ventriculostomy and septostomy with external ventricular drain placement. Although we were able to decompress the cysticercal cyst, unfortunately, the cyst got slipped from the grasper leaving the grasped cyst wall in the tooth of the grasper. Through this case report, we want to highlight that such a complication could also happen during neuroendoscopic cysticercal cyst removal and how we dealt with it. Our patient was discharged neurologically intact and was symptom free on follow-up.

Neurocysticercosis: challenges in pediatric neurosurgery practice

PURPOSE

Neurocysticercosis (NCC) is considered a neglected infectious disease, but the most common parasitic disease of the central nervous system (CNS). Due to oral tendencies in childhood, it is hypothesized that individuals are infected around this age and develop symptoms as lately as during young adulthood. Although it is considered a benign disease, it may cause great impact in the patient's quality of life due to epilepsy, visual symptoms, and hydrocephalus, which eventually requires frequent hospitalizations. The treatment of hydrocephalus is the main challenge for neurosurgeons.

METHODS

We performed a concise review on neurocysticercosis in children and the main presentations of NCC in the neurosurgery practice and a systematic review on hydrocephalus secondary to extraparenchymal NCC.

RESULTS

Our review showed a rate of complete resolution of hydrocephalus secondary to NCC of around 80% with the first attempt of surgical treatment combined with medication therapy. Endoscopic removal of the intraventricular cysts with third ventriculostomy was the most common treatment modality. Patients previously managed with ventricular shunts are likely to have worse outcomes and complications.

CONCLUSION

Endoscopic approach is the gold standard surgical treatment for hydrocephalus secondary to neurocysticercosis.

Single Burr-Hole Extended Transforaminal Approach for Concurrent Endoscopic Surgery in the Third Ventricle Posterior to the Foramen of Monro and Ventriculostomy: Clinical Series and Planning Steps

OBJECTIVE

For endoscopic surgery of third ventricular lesions posterior to the foramen of Monro that frequently require a third ventriculostomy during the same procedure, the extended transforaminal approach (ETFA) through the choroid fissure has been proposed. This study reports clinical results and provides anatomic background and guidelines for individual planning of a single burr-hole approach and a safe transchoroid entry zone.

METHODS

A retrospective review was undertaken of 25 cases of concurrent third ventricle surgery and third ventriculostomy via ETFA. Assessment was made of a safe transchoroidal entry zone on cadavers (6 hemispheres) and of planning guidelines on magnetic resonance imaging showing occlusive hydrocephalus (30 sides).

RESULTS

ETFA was feasible in all 25 cases. The safe transchoroid entry zone was sufficient in 16 cases; in 9 cases, additional transchoroid opening with transection of the anterior septal vein was required without clinical consequences. The anatomic study showed a safe transchoroid entry zone of 5 mm (3-6 mm) for posterior enlargement of the foramen of Monro. Individual planning on magnetic resonance imaging of patients with enlarged third ventricles showed an optimal burr-hole position 22 mm (10-30 mm) lateral to the midline and 8 mm (27 to -23 mm) precoronal; a foramen of Monro diameter of 7 mm (3-11 mm) and a safe transchoroid entry zone of 6 mm (3-12 mm).

CONCLUSIONS

According to our data, concurrent endoscopic surgery of third ventricular lesions posterior to the foramen of Monro and ventriculostomy are feasible through a single burr hole and a transchoroid extension of the transforaminal approach. Precise preoperative planning is recommended for anticipating the individual anatomic nuances.

Neurocysticercosis Presenting as an Isolated Suprasellar Lesion

BACKGROUND

Although extraparenchymal neurocysticercosis (NCC) is well established, presentation in the suprasellar space is rare. When presenting in the suprasellar space, the imaging characteristics may mimic more common lesions including craniopharyngioma and Rathke cleft cyst depending on the life cycle of the parasite. Although antiparasitic medical therapy may be effective for viable NCC, it is not routinely employed for calcified NCC.

CASE DESCRIPTION

This report presents a 39-year-old male patient who presented with profound visual decline secondary to a partially calcified suprasellar NCC. Suprasellar NCC was presumed based on specific radiologic findings, which are discussed. Medical therapy was not offered because of the proximity to the optic chiasm and the partial calcification of the lesion leading to the presumption that the mass was nonviable. The patient underwent successful endoscopic endonasal resection of the suprasellar NCC and experienced significant improvement in vision. Despite the calcification, pathological evaluation revealed that a portion remained viable.

CONCLUSIONS

Regardless of the life cycle stage, endonasal resection offers a minimally invasive approach for suprasellar NCC; treatment can be tailored to the patient's presentation and stage of infection.

Nonspecific dizziness as an unusual presentation of neurocysticercosis: A case report

RATIONALE

Neurocysticercosis (NCC) can cause lesions across the central nervous system, leading to varying clinical manifestations. While the presentation of nonspecific symptom is rare, they are easy to ignore. The present report documents a case of NCC that manifested as persistent dizziness.

PATIENT CONCERNS

A Chinese woman visited the hospital on account of dizziness, the severity of which had increased gradually over the month prior.

DIAGNOSES

Head computed tomography and magnetic resonance imaging (MRI) revealed hydrocephalus. Cervical MRI revealed an abnormal object in the spinal canal at the junction of the medulla oblongata and C1, which blocked the circulation cerebrospinal fluid circulation and caused the enlargement of the ventricles.

INTERVENTION

The patient underwent surgical treatment. The abnormal object was removed, and a diagnosis of NCC was considered by pathological examination.

OUTCOME

The patient's dizziness resolved after surgical treatment, and no other symptoms appeared thereafter.

LESSON

Clinicians should not ignore nonspecific clinical symptoms, as they may indicate hydrocephalus.

Solitary Cysticercal Cyst Inside the Blake's Pouch Remnant of Mega Cisterna Magna with Associated Aqueductal Stenosis: Clinical and Management Implications

BACKGROUND

Intraventricular and subarachnoid forms represent the relatively complex, albeit uncommon, manifestations of central nervous system involvement by cysticercal cysts. Cysticercal encystation inside the Blake's pouch remnant of mega cisterna magna (MCM) remains an extremely rare clinical scenario that, to the best of our knowledge, has not been reported previously.

CASE PRESENTATION

A 12-year-old boy presented with acute worsening and subsequent spontaneous resolution of his compensated hydrocephalus. Neuroimaging revealed features consistent with a MCM with septum inside, indicating remnants of the embryologic fourth ventricular diverticulum, the Blake's pouch. It also revealed a free-floating intact cysticercal cyst inside the MCM limited by the septum with aqueductal stenosis. The spontaneous clinicoradiologic resolution of hydrocephalus raised the possibility of ball valve obstruction of the cerebrospinal fluid outflow, i.e., Bruns syndrome. We successfully treated this patient with endoscopic extraction of the viable cysticercal cyst through a suboccipital burrhole.

CONCLUSIONS

The clinical scenario presented here has not been described previously. Endoscopic cyst removal in such a situation is an effective and low-risk procedure that obviates the further need for antihelminthic medications.

Surgical treatment of neurocysticercosis. Retrospective cohort study and an illustrative case report

CONTEXT AND OBJECTIVE:

Neurocysticercosis is prevalent in developing countries and manifests with several neurological signs and symptoms that may be fatal. The cysts may be parenchymal or extraparenchymal and therefore several signs and symptoms may occur. Depending on their location, neurosurgical procedures may be required, sometimes as emergencies. The aim here was to review 10-year statistics on all surgical neurocysticercosis cases at a large public tertiary-level hospital.

DESIGN AND SETTING:

Retrospective cohort at a large public tertiary-level hospital.

METHODS:

All surgical neurocysticercosis cases seen between July 2006 and July 2016 were reviewed. Parenchymal and extraparenchymal forms were considered, along with every type of surgical procedure (shunt, endoscopic third ventriculostomy and craniotomy). The literature was reviewed through PubMed, using the terms "neurocysticercosis", "surgery", "shunt" and "hydrocephalus".

RESULTS:

37 patients underwent neurosurgical procedures during the study period. Most were male (62.16%) and extraparenchymal cases predominated (81%). Patients aged 41 to 50 years were most affected (35.13%) and those 20 years or under were unaffected. Ventricular forms were most frequently associated with hydrocephalus and required permanent shunts in most cases (56.57%).

CONCLUSIONS:

The treatment of neurocysticercosis depends on the impairment: the parenchymal type usually does not require surgery, which is more common in the extraparenchymal form. Hydrocephalus is a frequent complication because the cysts often obstruct the cerebrospinal flow. The cysts should be removed whenever possible, to avoid the need for permanent shunts.

Cerebellar cysticercosis caused by larval Taenia crassiceps tapeworm in immunocompetent woman, Germany

Human cysticercosis caused by Taenia crassiceps tapeworm larvae involves the muscles and subcutis mostly in immunocompromised patients and the eye in immunocompetent persons. We report a successfully treated cerebellar infection in an immunocompetent woman. We developed serologic tests, and the parasite was identified by histologic examination and 12s rDNA PCR and sequencing.

Sellar cysticercosis and septum pellucidum cyst: a case report and review of the literature

Sellar cysticercosis is a rare form of neurocysticercosis. A septum pellucidum cysts is a rare, often asymptomatic cystic structure between the lateral ventricles. We report here a male patient with sellar cysticercosis and septum pellucidum cysts who was successfully treated by neuroendoscopic resection. The patient was a 28-year-old male who presented with intermittent headaches for 5 years. A magnetic resonance imaging (MRI) of the brain revealed a well-circumscribed 13 mm cystic space-occupying lesion in the sellar region and the cavum septum pellucidum. The cyst in the saddle area was completely resected via endoscopic endonasal-transsphenoidal approach. Postoperative histological examination verified cysticerci in the cyst wall. To our knowledge, this is the first case of sellar cysticercosis and a septum pellucidum cyst successfully treated through neuroendoscopic resection.

Third-ventricular neurocysticercosis: hydraulic maneuvers facilitating endoscopic resection

BACKGROUND

Neurocysticercosis, an infection of the central nervous system with the larval cysts of the pork tapeworm, Taenia solium, is the most common parasitic disease of the central nervous system. The disease is a major global cause of acquired epilepsy and may also manifest as intracranial hypertension due to mass effect from large cysts or to cerebrospinal fluid flow obstruction by intraventricular cysts or inflammation of the subarachnoid space. While the condition is endemic in several regions of the world and has been appreciated as a public health problem in such regions for several decades, its emergence in the USA in areas far from the Mexican border is a more recent phenomenon.

METHODS

We present a case of surgically corrected acute hydrocephalus in a recent Haitian emigrant child due to a third ventricular neurocysticercal cyst complex.

RESULTS

We describe the endoscope-assisted en bloc removal of the complex, together with hydraulic maneuvers facilitating the removal of the intact cyst.

CONCLUSIONS

Simple hydraulic maneuvers can facilitate the endoscopic en bloc removal of third ventricular neurocysticercal cysts.

Therapy for neurocysticercosis

Therapy for neurocysticercosis has advanced during the last 20 years with the advent of albendazole (Zentel) and praziquantel (Cysticide). Albendazole is the current medication of choice for the treatment of neurocysticercosis and is recommended for symptomatic patients with multiple viable cysts in the brain parenchyma. Albendazole may also be useful in extraparenchymal cysticercosis, especially in the subarachnoid racemose form, when complete surgical resection of the cysts is usually impracticable. Currently, there is an intense debate over the value and safety of anticysticercal therapy. Causes for failure of anticysticercal therapy include high inter-individual variability in plasma concentration of albendazole sulfoxide and the complex interactions of several drugs with the albendazole metabolite. Furthermore, albendazole sulfoxide is an enantiomeric mixture of (+)- and (-)-albendazole sulfoxide with accumulation of the (+)-enantiomer in the cerebrospinal fluid. However, the question over which enantiomer is effective against cysticerci remains to be clarified.

Current status and future perspectives on the medical treatment of neurocysticercosis

Neurological disease resulting from neurocysticercosis (NCC) is common in most of the world. The variability in the biology of the infection and in its clinical manifestations has led to much confusion regarding appropriate management. Therapeutic options have evolved from surgery, symptomatic measures, and steroids, to include the use of anti-parasitic drugs and minimally invasive neurosurgery. This manuscript reviews the principles of medical therapy for NCC, from discussion of the need for individualized management approaches for each type of NCC to exploration of the most likely potential additions or modifications currently under study.

What is the utility of postoperative antihelminthic therapy after resection for intraventricular neurocysticercosis?

BACKGROUND

Neurocysticercosis (NCC) is the most common worldwide parasitic infection of the central nervous system, and ventricular cysts are particularly problematic, carrying the risk of acute obstructive hydrocephalus. Herein, we present a typical case in which complete resection was possible and explore the evidence supporting the use of postoperative oral antihelminthic therapy.

METHODS

We performed a systematic review of the medical literature. Articles were included if they provided: 1) documentation of intraventricular disease, 2) discussion of management strategy, and 3) a presentation of outcomes. Available data were analyzed based on the primary therapy for NCC.

RESULTS

Data from 264 patients were abstracted from 32 references. Of all patients undergoing surgical resection of an isolated neurocysticercal cyst, 33.5% received postoperative antihelminthic therapy, most commonly albendazole. Among patients who had undergone surgical resection of a single intraventricular lesion (as was the case with our own patient), those who received postoperative antihelminthic therapy had a significantly lower risk of developing delayed hydrocephalus (18.8%, compared to 59.1% for those who received no medical therapy) (P = 0.02). The total mortality rate in our review was 3%.

CONCLUSIONS

This review produced surprising results: 1) the generous proportion of patients who underwent medical therapy as first-line treatment for intraventricular NCC (20.8%), and 2) the significant overall mortality. The data found in this review also provided for a strong consensus for the use of postresection antihelminthic therapy, and thus we elected to treat our index case with albendazole, assuming the risk to be low and the potential benefit meaningful.

[Surgical treatment of neurocysticercosis in a 12-year old child]

We present a case of neurocysticercosis in a 12-year old refugee from Zambia. Magnetic resonance imaging demonstrated a solitary, ring enhancing cystic lesion located subcortically in the left parietal lobe. Despite extensive diagnostic workup it was not possible to rule out alternative differential diagnoses. Serological tests for neurocysticercosis came out negative. The lesion was removed en bloc using microsurgical technique. Subsequent histological examination revealed a thick-walled cyst containing a cysticercus identifiable as a Taenia solium.

Isolated primary intradural extramedullary spinal neurocysticercosis: a case report and review of literature

BACKGROUND

In spite of being the most common parasitic infestation of central nervous system (CNS), spinal cysticercosis remains a rare entity.

CASE REPORT

We report an unusual case of a 45-year-old-male with primary isolated localization of spinal intradural extramedullary cysticercosis at thoracic 3/4 level. The lesion was surgically addressed to decompress the cord in combination with administration of oral albendazole. The weakness improved after treatment but the pain and numbness persisted. The available treatment options, diagnostic strategies and the pathophysiology of this rare condition are discussed here with a brief review of literature.

CONCLUSIONS

Clinicians should be aware of the diagnostic possibility of such a rare pathology. Neurosurgeons may face surgical challenges due to dense arachnoiditis associated with the degenerating lesion which may also account for the incomplete resolution of the symptoms even after treatment.

A case of extensive spinal cysticercosis involving the whole spinal canal in a patient with a history of cerebral cysticercosis

Although cysticercosis is the most common parasitic disease affecting the central nervous system, spinal cysticercosis is rare. A rare form of spinal cysticercosis involving the whole spinal canal is presented. A 45-year-old Korean male had a history of intracranial cysticercosis and showed progressive paraparesis. Spinal magnetic resonance scan showed multiple cysts compressing the spinal cord from C1 to L1. Three different levels (C1-2, T1-3, and T11-L1) required operation. Histopathological examination confirmed cysticercosis. The patient improved markedly after surgery.

Contemporary neurosurgical approaches to neurocysticercosis

Neurocysticercosis (NCC) includes a wide spectrum of illnesses. Newer neurosurgical approaches are being applied to NCC. Although clinical trials are leading to a consensus on medical management, fewer data address neurosurgical approaches. We reviewed all neurocysticercosis patients evaluated by neurosurgery at Ben Taub General Hospital, Houston, Texas, between August 1997 and December 2005. From 31 patients that had a neurosurgical evaluation, 16 patients were treated with shunts (5 had shunt failure requiring revision), 13 by surgical resection of cysts (9 underwent craniotomy and 4 endoscopy), and 2 by medical therapy. A fifth endoscopy was performed in one patient with shunt failure. None of the endoscopic patients needed another intervention. Despite the availability of anti-parasitic and anti-inflammatory therapies, neurosurgery continues to play an important role in the management of selected cases of NCC. In contrast to the high rate of shunt failure, neuroendoscopy seems to be associated with higher success rate than any other neurosurgical approach.

Neuronavigation guided surgery for parenchymal neurocysticercosis in two patients

Neurocysticercosis is a rare disease in the Baltic area while it is common in the endemic regions. Two patients with serologically negative parenchymal neurocysticercosis from our neurosurgical department who underwent extirpation of the cystic lesions with neuronavigation guided surgery are reported in this paper. Though most publications propose medical treatment with albendazole and praziquantel for parenchymal neurocysticercosis, surgery can be an option for diagnosis and treatment in conjunction with cysticidal medication if the diagnosis is unclear particularly in non-endemic areas.

Primary spinal intradural extramedullary cysticercosis

BACKGROUND

Spinal cysticercosis represents an uncommon localization of a common parasitic disease and, in most cases, is associated with intracranial involvement. Once confirmed, the entire neuraxis should be evaluated.

CASE DESCRIPTION

We present an unusual case of a 60-year-old male patient with isolated localization of spinal intradural extramedullary cysticercosis. The patient was treated successfully with the combination of surgical excision and orally administered albendanzole. We discuss the treatment options, the diagnostic screening, and the possible route of dissemination.

CONCLUSIONS

Because this is a rare but potentially life-threatening disease, clinicians should always take it into consideration in the differential diagnosis of spinal space-occupying lesions.

Second Case of Neurocysticercosis in a Patient With Liver Transplantation (First Case in Spain): A Case Report

BACKGROUND

Neurocysticercosis (NCC) is a disorder caused by the Taenia solium larva. It is the most common parasitosis of the central nervous system (CNS). Its distribution is universal, but it is endemic in many developing countries and in the third world. In Spain most patients come from countries where the condition is endemic. However, sporadic cases occur among the population of rural regions. NCC in transplant recipients is uncommon. One renal transplant recipient developed NCC but responded to treatment with praziquantel. Recently, it has been reported to complicate a liver transplantation.

CASE REPORT

The patient was a 49-year-old Ecuatorian man who received a cadaveric donor liver graft in June 2001 due to acute liver failure induced by toadstool and was under treatment with FK506. In January 2006, the patient presented with a generalized onset of a tonic-clonic seizure for 1 minute without sphincter incontinence, headache, fever, or previous brain trauma. Neurological evaluation did not show evidence of organic brain dysfunction. The neuroimaging findings (brain) computed tomography scan, magnetic resonance imaging were compatible with NCC: many cystic lesions intra- and extraparenchymatous with a scolex visible in three of them. Serology for cysticercosis in plasma was initially indeterminate but positive afterward. The patient was treated with anticonvulsivants (valproic acid) and albendazole. Systemic steroids were added in order to reduce the edema produced upon death of the cyst. Treatment lasted 3 weeks and it was completed without complications or neurological symptoms. Liver function was not affected. One year later the patient remained asymptomatic.

CONCLUSION

NCC is a condition that must be included in the differential diagnosis of patients with CNS involvement and cystic lesions on neuroimaging investigations in transplant recipients, especially patients originating from or traveling to endemic areas. First-line therapy for active cysts includes antiparasitic drugs (albendazole or praziquantel) as well as steroids and anticonvulsivants. In our patient, this therapy was effective.

Neurocysticercosis in the HIV era: a case report and review of the literature

The prevalence of HIV is increasing in countries where neurocysticercosis is endemic. Co-infection rates are expected to rise; however, no systematic reviews of the subject are available. We performed a literature review of neurocysticercosis (NCC) occurring in HIV-infected patients and described the clinical and immunophenotypic characteristics of a NCC case presenting with probable immune reconstitution inflammatory syndrome. We identified 27 cases of NCC-HIV co-infection. The most frequent presentation (61%) was with multiple parenchymal lesions. Seven patients (30%) had other concomitant neurologic infections (e.g., tuberculosis, toxoplasmosis). Thirteen patients received cysticidal therapy, and 85% responded to therapy. Only three patients died (12%). Immunohistochemistry of brain tissue in our case revealed abundant CD3+, CD8+, and CD68+ cells. NCC should be included in the differential diagnosis of neurologic infections in HIV patients in endemic populations. Consideration of the patient's immune status should alert the clinician to potential atypical presentations.

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.

Malignant transformation of high-grade astrocytoma associated with neurocysticercosis in a patient with Turcot syndrome

A 45-year-old woman with anaplastic astrocytoma was clinically diagnosed with Turcot syndrome, and subsequently developed simultaneous neurocysticercosis and malignant transformation to glioblastoma. The parasitic cysts and glioblastoma were microsurgically removed. Histological examination of surgical specimens revealed neurocysticercosis between the normal brain tissue and glioblastoma. The clinical course and histological findings suggest that the parasitic infection and/or genetic changes contributed to the malignant transformation of the astrocytic tumour.

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.

Spinal cord cysticercosis: a case report

Cysticercosis caused by the infection with the larva of Taenia solium, common through out the world, is located in the muscles, the eyes and the central nervous system, but mostly in the brain. Spinal cord infection is rare. The authors report a case of a young girl, living in Paris who had traveled in Latin America, and complained of back pains and troublesome walking. MRI showed a cyst in spinal cord, but other examinations were normal. Diagnosis was confirmed by a pathologist. It was a pure intramedullary cysticercosis, the check-up to find other locations was negative. Only approximately 130 cases are reported in the literature, with motor and sensory disorders. The diagnosis was based on MRI and pathological examination. Antiparasitic medical treatment was useful when combined with surgery.

Giant neurocysticercosis cyst in the cerebellar hemisphere

A 67-year-old man presented with dizziness, nausea, and ataxia. Magnetic resonance imaging showed a large (5.5 x 4 x 4 cm) cystic lesion in the left cerebellar hemisphere with internal septation, a mural nodule, and thin rim enhancement. Cystic cerebellar tumor such as hemangioblastoma was initially suspected. Following surgery, the cyst was identified as cerebellar neurocysticercosis. Neurocysticercosis is the most common parasitic disease of the central nervous system but is occasionally misdiagnosed as tumor because of the varying neuroimaging presentation. This case shows that neurocysticercosis should be considered in the differential diagnosis of giant cystic lesions in the cerebellum as surgical intervention may be unnecessary.

Neurocysticercosis: surgical treatment of an autochthonous case in a non-endemic region

OBJECTIVE AND IMPORTANCE

This study describes a case of autochthonous neurocysticercosis in a non endemic region where a differential diagnosis with more frequent single parenchymal lesions must be carried out.

CLINICAL PRESENTATION

The patient presenting generalized seizures and coma status under the suspicion of cerebral neoplasia was admitted to the neurosurgery division. MRI showed the presence of an ovoidal cystic lesion in right-frontotemporal region.

INTERVENTION

After right fronto-temporal osteoplastic bone flap elevation and usual dural tacking and opening, trans-scissural subaracnoid access was made possible by microsurgical strumentation in right Sylvian fissure. A cystic, translucid lesion was identified in the deep Sylvian fissure, involving the distal segment of the fissure and the frontal lobe, the cystic lesion was removed surgically. Pathological examination showed a typical picture of neurocysticercosis.

CONCLUSIONS

After both surgical and chemotherapeutic treatment with albendazole the outcome was successful. The diagnosis of neurocysticercosis should be taken into account in the presence of generalized seizures possibly due to single parenchymal lesions, even in non-endemic regions for this parasitic infection.

Bruns syndrome caused by intraventricular neurocysticercosis treated using flexible endoscopy

Object

Neurocysticercosis is the most frequent cause of hydrocephalus in adults in regions where the disease is endemic, including Latin America. The prognosis for intraventricular neurocysticercosis is worse than that for the intraparenchymal form of the disease, making treatment especially important. Although active and viable intraventricular cysts produce no reaction in the host, they can cause noncommunicating hydrocephalus, whose onset is frequently abrupt. Sometimes the increasing intracranial pressure due to obstruction of the cerebral aqueduct (ball-valve mechanism) is intermittent, producing relapsing/remitting symptoms; this life-threatening phenomenon is called “Bruns syndrome.”

Methods

Between 1996 and 2004, among a group of 285 patients with neurocysticercosis and Bruns syndrome caused by cysticercal cysts of the third ventricle was diagnosed in seven patients by using magnetic resonance imaging. An endoscopic procedure with a flexible cerebral endoscope was performed, intact parasitic cysts were removed, and a complete exploration was undertaken to look for more cysticercal cysts in the whole ventricular system and the subarachnoid basal cisterns. There were no deaths or complications. All seven patients were asymptomatic during a follow-up period ranging from 1 to 5 years.

Conclusions

Flexible cerebral endoscopy allows one, in a minimally invasive manner, to approach the ventricular system and subarachnoid basal cisterns and to remove intraventricular neurocysticercal cysts. Flexible endoscopy is an alternative treatment for Bruns syndrome caused by neurocysticercosis of the third ventricle.

Intramedullary spinal cysticercosis simulating a conus medullaris tumor: case report

Cysticercosis is an endemic condition in many developing countries. Although it is the most common parasitic disease of the central nervous system, cysticercal involvement of the spinal cord is rare. It may occur as intradural extramedullary, intramedullary, intramedullary associated with intradural-extramedullary or as the vertebral presentation. We report the case of a 53-year-old woman who presented with low back pain of acute onset and no other symptoms. Magnetic resonance imaging (MRI) showed an intramedullary cyst of the conus medullaris region which, at pathological examination, was diagnosed as a cysticercal cyst. She refused anticysticercal agents and steroids postoperatively. After an eight-year follow-up, the patient performs the activities of her daily living with no difficulties, and annual spinal MRIs show no residual signs of the disease. Clinical, pathophysiological, diagnostic and therapeutic aspects of spinal cord intramedullary cysticercosis are discussed.

Solitary Fourth Ventricular Neurocysticercosis Presenting as Status Migrainosus

Fourth ventricular cysts in patients with neurocysticercosis are generally solitary without accompanying parenchymal cysts and hence present with hydrocephalic symptoms at the time of implantation. We report a patient with status migrainosus-like presentation in whom the neurological examination was normal and the diagnosis was made by imaging (CT and MRI scan).

The role of epilepsy surgery in southern Africa

Epilepsy surgery plays an important role in the management of patients with medically refractory temporal lobe epilepsy and lesional epilepsies. When performed early in the course of the illness, surgery can render many patients seizure-free and greatly improve their quality of life. In southern Africa, as in many developing nations, thousands of patients could benefit from epilepsy surgery, but inequalities in healthcare provision mean that ready access to surgical facilities is largely restricted to those with private healthcare insurance. Over the past 5 years, more than 250 patients have had epilepsy surgery in Cape Town; the cause of epilepsy in six of these individuals was neurocysticercosis resulting from central nervous system infection by the larval stage of the pork tapeworm (Taenia solium), which is a common cause of epilepsy in the tropics. In all cases, surgery was successful, with patients becoming seizure-free and reporting a much improved quality of life.

Hydrocephalus and racemose cysticercosis

BACKGROUND AND PURPOSE

Hydrocephalus is a frequent and potentially serious complication of neurocysticercosis. Its treatment often requires ventricular shunting. The complication rate is high due to obstruction or material infection, which may justify endoscopic third ventriculostomy (ETV).

OBSERVATION

We report a case of obstructive hydrocephalus in a 46-year-old man in the context of racemose cysticercosis, presenting with headaches and transient disorders of consciousness. Imaging showed cystic lesions of the cisterna magna, responsible for hydrocephalus which was treated effectively by ETV. Treatment with albendazole decreased the volume of the cisterna magna cysts.

RESULTS

The patient was followed for 6 years after ETV with no recurrence of hydrocephalus despite two more symptomatic episodes of the disease with extension of the cysts into the lumen of the fourth ventricle and into the perispinal subarachnoid spaces, effectively treated by albendazole each time.

CONCLUSIONS

Treatment of obstructive hydrocephalus secondary to cerebral racemose cysticercosis by ETV seems to be an effective and safety technique. The role of ETV should be evaluated in this indication.

Inflammatory aneurysm due to neurocysticercosis

A 69-year old man presented with a subarachnoid hemorrhage associated with a large intracerebral hematoma in the right temporal lobe. The oblique views of cranio-orbital computerized tomographic angiography (CTA) were suspicious for an aneurysm on a middle cerebral artery branch. At surgery, a cystic mass was found in the Sylvian fissure, associated with an aneurysm on a distal branch of the anterior temporal artery. The aneurysm was not situated at a bifurcation of the artery and was located beneath the cyst. It was secured by trapping. Pathological examination revealed that the cystic lesion was neurocysticercosis and that the aneurysm was inflammatory. We report a ruptured inflammatory aneurysm of a distal branch of the anterior temporal artery associated with neurocysticercosis, and present the histological findings. We believe this is the first report of such an inflammatory aneurysm with histological confirmation.

Endoscopic Third Ventriculostomy for Patients with Hydrocephalus and Fourth Ventricular Cysticercosis: A Review of Five Cases

The authors evaluate the feasibility of performing endoscopic third ventriculostomy (ETV) in a series of five patients with ventricular outlet obstruction and a prior history of fourth ventricular cysticercosis. All patients underwent fourth ventricular cyst excision and presented at various times afterwards with hydrocephalus. They were all successfully managed with ETV, and no patient has required subsequent surgery during a mean follow-up period of 21 months (range 12-36 months).

Surgical treatment for mesial temporal lobe epilepsy in the presence of massive calcified neurocysticercosis

BACKGROUND

Neurocysticercosis (NCC) is the most common parasitic disease of the human central nervous system and a major health problem for most developing countries. The most common clinical manifestations of NCC are epileptic seizures. Whenever epilepsy and NCC coexist in the same patient, an uncertainty may rise about a causal relationship between them.

OBSERVATION

We described a female patient with disseminated calcified NCC lesions and intractable epilepsy. Her medical history included cysticercotic meningoencephalitis and status epilepticus caused by active NCC. Fundoscopy showed the ocular presence of parasite; computed tomography of the brain showed evidence of cystic lesions with the scolex and calcified lesions; enzyme-linked immunosorbent assay of the cerebrospinal fluid was positive for cysticercosis. Epileptic seizures started after an 8-year silent period. Magnetic resonance imaging showed left hippocampal sclerosis. Plain x-ray film showed calcifications in muscles and subcutaneous tissue. Video-electroencephalography and ictal and interictal single-photon emission computed tomography disclosed left mesial temporal lobe epilepsy. The patient underwent left temporal lobectomy and has been seizure free since surgery, for a follow-up of 4 years.

CONCLUSION

This case report highlights and supports surgical therapy in patients with epileptic seizures and calcified NCC, even when there are several calcifications, provided that clear localization of epilepsy has been determined by means of a presurgical workup.

Diagnosis of intraventricular cysticercosis by magnetic resonance imaging: Improved detection with three-dimensional spoiled gradient recalled echo sequences

Neurocysticercosis (NCC) is caused when the cysticercus larvae of Taenia solium infect the central nervous system. The larvae usually land in the parenchymal tissue, but quite rarely can lodge in the ventricles and cisterns of the brain. Unlike parenchymal NCC, it is not easy to demonstrate the cysticercus cysts within the cerebrospinal fluid spaces. Computed tomography and even conventional MR sequences can fail to detect such cysts. However, obtaining three-dimensional spoiled gradient recalled echo imaging sequences can help in improving the detection of intraventricular NCC, as is borne out by a case described in the present report. The use of such special MR sequences is therefore strongly advocated in suspected cases of intraventricular NCC.