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Articulo Neurocisticercosis
Articulo Neurocisticercosis
(after
32
)
Level of
criteria
Findings
Absolute Pathologic demonstration of the parasite; CT scans or MRI showing a cystic lesion with scolex; direct funduscopic visualization of parasite
Major Lesions highly suggestive of neurocysticercosis on neuroimaging; positive serum enzyme-linked immunoblot assay for cysticercal antibodies; resolution of
cysts after antiparasitic therapy; spontaneous resolution of a small solitary enhancing lesion
Minor Lesions compatible with neurocysticercosis on neuroimaging; clinical manifestations suggestive of neurocysticercosis; positive cerebrospinal uid enzyme-
linked immunosorbent assay for anticysticercal antibodies or cysticercal antigens; cysticercosis outside of the central nervous system
Epidemiologic Household contact with Taenia solium infection; immigrants from or living in an endemic area; history of frequent travel to disease-endemic areas
Diagnosis: denitive one absolute criterion or two major + one minor + one epidemiologic criterion; probable one major + two minor criteria, or one major + one
minor + one epidemiologic criterion, or three minor + three epidemiologic criteria.
Fig. 8. Noncontrast axial CT Scan showing a fourth ventricular cyst with obstructive
hydrocephalus. Note the deformation of the shape of the ventricular cavity and the
same density of the cyst and cerebrospinal uid, making them indistinguishable.
870 S. Sinha, B.S. Sharma / Journal of Clinical Neuroscience 16 (2009) 867876
extracranial cysts in temporalis or nuchal muscles.
38
On positive
contrast ventriculography, the presence of a regular, rounded ll-
ing defect similar to an inverted cup suggests the presence of a cyst
and denes its extent, contour and mobility,
40
whereas a cul-de-
sac suggests inammatory obstruction. A cyst within the third ven-
tricle may mimic a colloidal cyst.
41,42
The patients with epilepsy frequently have SSELs. SSELs are the
commonest cause of partial seizures in children in India.
35,37,38
Most of these lesions represent solitary cerebral cysticercus granu-
loma (SCCG). SCCG is the granulonodular form of the parenchymal
cyst and accounts for nearly 60% to 70% of all forms of NCC seen in
patients in India.
38
The differential diagnosis of SSEL includes tuberculoma, pyo-
genic brain abscesses, fungal abscess, toxoplasmosis, a primary or
metastatic brain tumor and infectious vasculitis. The diagnosis re-
lies on associated features, especially in those with uncertain imag-
ing. Serology is also often negative in patients with SCCG, because
the parasite is already dead or because a sole parasite does not eli-
cit a strong antibody response. However, many patients with
tuberculoma do not have detectable tuberculosis in the lungs or
in any other location to conrm the diagnosis. Rajshekhar et al.
16
described CT scan criteria for differentiating NCC and tuberculoma.
An enhancing ring lesion that is <20 mm in size, regular in outline
and not producing a midline shift is likely to be NCC. However, the
authors themselves believe that these criteria are not absolute and
it may be difcult to differentiate a small tuberculoma from NCC
on a CT scan alone. MRI has better sensitivity to differentiate tuber-
culomas from NCC. Preliminary experience with proton magnetic
resonance spectroscopy has shown promise in differentiating
tuberculoma from NCC.
43
4.1.3. MRI of the brain
MRI is the most accurate technique to assess degree of infection,
location and evolutionary stage of the parasite. MRI is able to de-
tect perilesional edema and degenerative changes of the parasite
and is suitable for small cysts or those located in the ventricles,
brainstem, cerebellum, base of the brain, eye and spine.
44
The main
disadvantages of MRI are its high cost and limited availability.
Thus, in our Indian center, a CT scan may be the rst investigation,
reserving MRI for patients with inconclusive CT ndings.
It is possible to differentiate the various cyst stages on MRI.
45
The intensity of uid in live cysts is similar to CSF. The scolex ap-
pears as a mural nodule of high signal intensity on T1-weighted
MRI and of low signal intensity on T2-weighted MRI (like a hole
with a dot, or a pea in a pod) (Fig. 5). There is no perilesional edema
at this stage.
46
In a degenerated cyst, the uid becomes turbid (col-
loid vesicular stage), appearing as high intensity on a T1-weighted
MRI. In the granulonodular stage, ring enhancement occurs on gad-
olinium injection (isointense on T1-weighted and hypointense on
T2-weighted MRI) and there is variable perilesional edema. How-
ever, calcied cysts are better delineated on CT scans. The race-
mose type of cyst is a large lobulated cyst without a scolex
whereas the cellulose type contains a scolex inside a vesicle. Intra-
ventricular cysts (Figs. 912) are well delineated with a small
metacystode inside the cyst.
47
Abnormal enhancement after gado-
linium suggests ependymitis or ventricular entrapment (Fig. 12).
48
MRI is useful in follow-up to assess reduction in the number or size
of cysts with treatment.
4.2. Serology
The available serological tests are of little value in clinical prac-
tice. These have a sensitivity of 65% to 98% and a specicity of 67%
to 100%, depending on the specic test used, and the cyst burden,
location, and phase of infection.
4951
The most commonly used en-
zyme-linked immunosorbent assay is neither sensitive nor spe-
cic.
49
EITB is reported to have a sensitivity of 98% and
specicity of 100%, and it is the test of choice as a major diagnostic
criterion.
50
However, its sensitivity in a patient with a single
enhancing or calcied lesion is much lower.
51
Fig. 9. T1-weighted Axial MRI showing a well-delineated fourth ventricular cyst.
Fig. 10. T1-weighted sagittal MRI showing a well-delineated fourth ventricular cyst
with obstructive hydrocephalus.
S. Sinha, B.S. Sharma / Journal of Clinical Neuroscience 16 (2009) 867876 871
Serology should be used together with clinical and neuroimag-
ing data. Antigen detection assays are also available, which per-
form well in comparison with other available tests on CSF
samples.
52
Antibodies can persist after cysts die; therefore, serol-
ogy should always be reviewed in light of the presenting clinical
picture and imaging studies.
36
4.3. Other tests
Biopsy of brain, skin or muscle can provide a denitive diagno-
sis in an otherwise ambiguous clinical situation and may be the
diagnostic method of choice for ocular, extraocular muscle, or
painful muscular or subcutaneous cysts.
5,5355
Dilated ophthalmologic examination is sensitive for the detec-
tion of ocular cysts and is necessary for anyone diagnosed with
cysticercosis to rule out ocular involvement.
54
5. Treatment
The treatment modalities available to patients with NCC
include:
1. cysticidal agents to kill larvae
2. corticosteroids to decrease or prevent the inammatory
reaction.
3. anti-epileptic drugs (AEDs) to prevent or decrease the severity
and number of seizures
4. surgery to remove the cyst or insert a shunt for hydrocepha-
lus. Garcia et al. analyzed the current evidence and reported
consensus guidelines for the management of NCC
56
(Table 3).
5.1. Cysticidal agents
5.1.1. Is cysticidal therapy needed?
There are three major arguments against the use of cysticidal
therapy in NCC: (i) immediate risks due to acute inammation
from the death of cysts; (ii) worsening of long-term prognosis of
seizures with increased scarring due to acute inammation,
57
and (iii) treatment may be unnecessary due to natural death of
the parasites within a short period.
58
According to a Cochrane
Database Systematic Review, there is insufcient evidence to as-
sess the benecial effects of cysticidal drugs in NCC.
59
However,
in a double-blind, placebo-controlled study in patients with sei-
zures resulting from viable parenchymal cysts, cysticidal therapy
decreased the burden of parasites and was effective in reducing
the number of generalized seizures.
60
A recent meta-analysis
showed that there is a reduced seizure rate and increased resolu-
tion of parenchymal lesions with cysticidal therapy.
61
The clinical benet from cysticidal therapy in the treatment of
SSELs is also controversial. A few trials from India have assessed
the efcacy of cysticidal therapy for SSEL in adults and chil-
dren.
15,6264
More complete resolution on imaging and fewer sei-
zures during follow-up were reported in an albendazole group in
two of these trials.
63,64
In contrast, Gogia et al.
65
did not show
any benet of albendazole in hastening resolution of CT lesions.
Fig. 12. Gadolinium-enhanced sagittal MRI of a patient showing an inammatory
cyst with enhancement of the cyst wall and surroundings.
Table 3
Guidelines for the treatment of neurocysticercosis (after
56
)
Type of neurocysticercosis Treatment
Parenchymal
neurocysticercosis
Viable cysts Cysticidal treatment + steroids
Calcied AED no cysticidal therapy
Enhancing lesions Single AED, cysticidal drugs if persistent
Multiple AED, cysticidal drugs + steroids
Cysticercotic encephalitis High dose steroids + osmotic diuretic or
immunosuppressive therapy + cysticidal therapy
Extraparenchymal
neurocysticercosis
Intraventricular cyst Neuroendoscopic removal
Subarachnoid cyst Cysticidal treatment + steroids; VP shunt if
required
Hydrocephalus with no
viable cyst
VP shunt, no cysticidal treatment
Hydrocephalus + intracranial
cyst
Shunt before cysticidal therapy
Ocular cysticercosis Surgery (cysticides avoided)
Spinal cysticercosis Surgical treatment
AED = antiepileptic drugs, VP = ventriculoperitoneal.
Fig. 11. A,B. T2-weighted coronal (A) and sagittal (B) MRI showing a rounded well-
dened cyst in the fourth ventricular cavity with a hyperintense scolex.
872 S. Sinha, B.S. Sharma / Journal of Clinical Neuroscience 16 (2009) 867876
However, some authors would not recommend leaving a live
parasite untreated in the brain.
60
Thus, although there is contro-
versy regarding the routine use of cysticidal drugs in SSELs, cysti-
cidal drugs are generally considered helpful in the management
of some patients (such as those with persisting lesions) as they
hasten the resolution of the lesion, and thus, may avoid diagnostic
pitfalls.
5.1.2. Cysticides
Cysticidal drugs, albendazole and praziquantel, are effective in
all forms of NCC.
1,7,61,66,67
Praziquantel (an isoquinolone) produces spastic paralysis of the
parasite and destroys the scolex. About 60% to 70% of parenchymal
cysticerci disappear after a 15-day treatment at doses of 50 mg/kg
per day.
6870
Recently, ultrashort single-day therapy with prazi-
quantel has been introduced, and the reduction in cyst number
has been the same as for longer courses of treatment.
7174
Albendazole (an imidazole) acts by inhibiting glucose uptake by
parasitic membranes thereby causing energy depletion. About 75%
to 90% of parenchymal cysts disappear, and albendazole is consid-
ered superior to praziquantel in several trials.
7577
Other points
favoring albendazole are its efcacy against meningeal, subarach-
noid and ventricular cysticerci, and its lower cost. Albendazole
does not interact with corticosteroids or antiepileptic drugs.
78
It
was initially recommended to be administered at a dosage of
15 mg/kg per day for 1 month, but later studies showed that a 1
week course of albendazole is equally effective and is probably
more effective than praziquantel.
60,79,80
Infections with more than
a few lesions may require longer courses of anti-parasitic medica-
tion.
61
The optimal duration of cysticidal therapy for other less
common forms such as giant cysts or subarachnoid forms is un-
known but should perhaps be longer than for parenchymal NCC.
56
An additional course of praziquantel can be given if cystic le-
sions remain unchanged on repeat MRI after 1 month to 2 months
of therapy. However, with a partial response to one cysticidal drug,
administration of the other cysticide (such as albendazole 15 mg/
kg per day in 2 divided doses for 8 days) is probably better than
repetition of the same drug course.
66
Intraventricular cysts have generally been excised, but many
authors have reported disappearance of intraventricular and sub-
arachnoid cysts with cysticidal therapy.
48
A recent trial suggests
that a high dose of albendazole (30 mg/kg per day) increases clear-
ance of subarachnoid and intraventricular cysts, as compared with
usual dosing.
81
However, regardless of the treatment chosen, a
ventriculoperitoneal shunt should be placed in all patients with
evidence of signicant obstructive hydrocephalus. Steroids should
be commenced prior to cysticidal treatment to reduce the risk of
shunt obstruction. There are concerns of catastrophic complica-
tions with cysticidal treatment due to ventriculitis and recurrent
obstruction of the ventricular drainage system.
42
Corral et al.
26
successfully treated intramedullary spinal cysti-
cercosis with cysticidal therapy. In the meningeal form, cysticidal
treatment may give only marginal benet and the prognosis is
poor due to hydrocephalus, meningeal brosis and multiple brain
infarcts secondary to vasculitis. In these patients administration
of 50 mg prednisolone 3 times per week may be useful to prevent
or diminish chronic inammation.
66,67
5.2. Corticosteroids
Corticosteroids are used as adjuncts to cysticidal therapy to
alleviate symptoms due to the inammatory reaction caused by
the death of larvae, which occurs from 2 days to 5 days after initi-
ating therapy. There is conicting evidence to support corticoste-
roid use as the primary treatment in SSELs;
82,83
however, high
dose corticosteroids are the primary therapy for cysticercotic
encephalitis. Steroids should be given with cysticidal drugs for pa-
tients with subarachnoid cysts, chronic meningitis or multiple via-
ble cysts. Oral prednisolone is preferred and should be commenced
2 days to 3 days before cysticidal therapy and continued for 7 days
to 10 days, since maximum exacerbation occurs during this period.
Long-term steroid therapy depends on the parasite load and
inammation. All trials to evaluate cysticidal therapy have used
steroids for a variable period of time.
64,82
5.3. Anti-epileptic drugs
A single agent rst-line AED such as phenytoin or carbamaze-
pine usually results in adequate seizure control. The optimal dura-
tion of AED therapy has been debated and is estimated by
identifying the parasite stage at the time of the seizure.
84
Patients
with degenerating cysticerci develop acute symptomatic seizures
because of the inammatory response of the brain. Therefore, these
patients may be treated for the duration of the acute condition
only, perhaps several months, during the active inammatory re-
sponse. There are, however, no guidelines for how long AEDs
should be continued after an acute episode. For patients with SCCG,
it is most appropriate to monitor cyst activity with neuroimaging
and to continue AEDs until resolution of the acute lesion. Most
physicians repeat MRI or CT scans after 6 months in patients with
parenchymal cysticercosis (earlier if the patient is symptomatic).
Once the lesion has resolved on neuroimaging, the AED may be ta-
pered off over the next 12 weeks. However, seizures in a patient
with inactive or calcied parasites may be categorized as unpro-
voked seizures. The treatment should last until the patient has
experienced a seizure-free period of 2 years. Treatment in patients
with multiple lesions or extraparenchymal NCC should be tailored
to the individual.
5.3.1. Future research
More studies are needed to study the prevention of disease
spread and to further elucidate treatment regimes. The Center for
Disease Control and Prevention Working Group on Parasitic Dis-
eases has classied cysticercosis as a potentially eradicable dis-
ease.
85
Recent studies have demonstrated the potential utility of
various vaccines against Taenia solium for use in pigs, but their
widespread use is not yet a reality.
86,87
5.4. Surgery
In general, indications for surgery are:
1. cysts exhibiting local compression of brain and cranial nerves.
2. pseudotumor (edema) refractory to medical treatment.
3. hydrocephalus.
4. intraventricular cysticercosis.
5. intracranial hypertension.
6. spinal cysticercosis with cord/ root compression.
7. ocular cysts.
54
5.4.1. Extraparenchymal forms
5.4.1.1. Cisternal forms. Patients with the cisternal form of NCC usu-
ally have racemose cysts in the basal cisterns and are prone to
symptoms that result from local compression. Direct excision of
these cysts is not recommended and can be dangerous due to se-
vere adhesions. However, excising individual cysts that cause local
compression can be benecial for local compressive symptoms, but
is not helpful to reduce the inammatory reaction.
5.4.1.2. Ventricular forms. The indications for excision of a viable
ventricular cyst are: (i) mass effect, (ii) CSF obstruction, (iii) uncer-
tain diagnosis, and (iv) fourth ventricular cysts, as they may cause
S. Sinha, B.S. Sharma / Journal of Clinical Neuroscience 16 (2009) 867876 873
brainstem compression even after shunt placement. The treatment
options for ventricular NCC include medical therapy, CSF diversion
and surgical resection by microsurgery and/or endoscopy. Repeat
imaging should be performed immediately before surgical inter-
vention, to exclude cyst migration between the time of diagnosis
and surgery.
The development of acute hydrocephalus requires an emer-
gency ventriculostomy, especially if the patient has an altered level
of consciousness, followed by denitive resection of cysts. A ventri-
culoperitoneal shunt may be required thereafter, once the cysts
have been resected, especially in the presence of ependymitis.
41
Due to the frequency of ventriculitis, shunt failure rates have been
reported as high as 30% to 67%. Therefore, multiple shunt revisions
may be required in these patients, with a high mortality rate (50%
in 2 years).
8891
Direct microsurgical excision via a posterior fossa exploration is
invasive and carries a high risk of morbidity and mortality. Sharma
et al. reported posterior fossa craniotomy for fourth ventricle cysts
and supratentorial open or stereotactic craniotomy for third or lat-
eral ventricular cysts.
91
Endoscopic approaches for ventricular NCC have been de-
scribed
92102
and have become the treatment of choice for ventric-
ular NCC with hydrocephalus. The neuroendoscopic approaches to
treatment of NCC have many advantages including the avoidance
of a shunt with its attendant complications,
89,92,94,96,97,99
quick
and easy navigation within the ventricles and excision of multiple
ventricular cysts with minimal postoperative complications.
Proano et al. reported endoscopic exploration of the fourth ven-
tricle entrapped secondary to vasculitis.
48
Later, Bergsnaider et al.
reported a transvalecular exploration of fourth ventricular NCC
with removal of cysts in 5 patients.
96,97
The transfrontal transaqu-
eductal approach was rst described by Schroeder and Gaab for the
treatment of aqueductal stenosis.
103
The use of this approach for
the removal of ventricular NCC was reported by Anandh et al.
(using a exible endoscope)
99
and Zymberg et al. (using a rigid
endoscope).
102
Hussain et al. recommend a transventricular trans-
foraminal approach to remove a third or even a fourth ventricular
cyst and to perform an endoscopic third ventriculostomy at the
same time, through a single burr hole. They used a 5 Fr. angio-
graphic catheter and passed it through the rigid endoscope to
negotiate through the aqueduct. In their series, minimal periaqu-
eductal contusions developed in 3 patients due to catheter negoti-
ation, although none had any sequelae.
9294
In their series of 13
patients, Suri et al. used a exible endoscope and passed it through
a rigid scope to negotiate the catheter through the aqueduct under
direct vision. A long exible biopsy forceps was then used to excise
the fourth ventricular NCC. This avoided the chance of periqueduc-
tal injury and all their patients had normal extra-ocular move-
ments postoperatively.
104,105
Many series have reported aspiration of the contents of the cyst
prior to its removal, as a collapsed cyst is easier to handle and re-
trieve.
92,94,101
Although there are some concerns regarding ventric-
ulitis after perioperative cyst rupture, techniques such as
preoperative continuous irrigation with Ringers solution and post-
operative lumbar drainage can clear debris and maintain ventricu-
lar patency.
However, despite advantages, neuroendoscopic procedures
have some potential drawbacks and limitations.
48,97,99,101
Firstly,
endoscopic excision may be hazardous in presence of ependymitis
and dense adhesions. Therefore, patients in whom MRI demon-
strates signicant ependymal enhancement are considered poor
candidates for this procedure and should probably undergo shunt
placement. Secondly, intraventricular bleeding can be problematic.
5.4.1.3. Encephalitic forms. Patients with the encephalitic form of
NCC have diffuse cerebral edema due to multiple cysticerci in the
brain parenchyma. Treatment of this form is primarily medical in
order to reduce the raised intracranial pressure. However, decom-
pressive craniotomy has been recommended for these patients
with only transient benets; now, with more effective means to
control raised intracranial pressure, most authors would not advise
this.
106
5.4.1.4. Parenchymal forms. For parenchymatous NCC, the following
surgical approaches are recommended:
1,21,24,88,107109
1. Stereotactic excisonal biopsy or open craniotomy and cyst
removal is recommended for a single giant cortical cyst or large
clumps exhibiting tumor-like behavior, provided that the lesion
is surgically accessible, is producing progressive decits or is
not responding to cysticidal treatment. This approach may also
be used when diagnosis is uncertain (e.g. a SSEL is not respond-
ing to cysticides) or multiple lesions. Supratentorial decompres-
sive craniotomy, craniectomy or lobectomy is undertaken when
the psuedotumor-type edema is refractory to medical treat-
ment, particularly in the disseminated variety.
2. For spinal cysticercosis, excision needs to be undertaken. Intra-
medullary and clumped leptomeningeal cysts producing symp-
toms by mass effect and not responding to cysticidal drugs can
be removed via laminectomy. When diagnosis is in doubt, sur-
gery helps in getting a histopathological diagnosis.
108
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