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NEURORADIOLOGY Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 775-778
Lateral ventricular neurocysticercosis: A case report


Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, U.P., India

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Date of Submission03-Apr-2006
Date of Acceptance10-Aug-2006
 

Keywords: Neurocysticercosis, Intraventricular, Hydrocephalus

How to cite this article:
Kalra S, Jaiswal A K, Behari S, Jain V K. Lateral ventricular neurocysticercosis: A case report. Indian J Radiol Imaging 2006;16:775-8

How to cite this URL:
Kalra S, Jaiswal A K, Behari S, Jain V K. Lateral ventricular neurocysticercosis: A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2020 Jan 18];16:775-8. Available from: http://www.ijri.org/text.asp?2006/16/4/775/32345
Cysticercosis is a parasitic infection with CNS involvement in 60-90% of infested patients. The larval form of pork intestinal tapeworm Taenia solium is the agent responsible for cysticercosis. Humans are the definitive hosts and usually harbor the adult tapeworm in small intestine as an asymptomatic infestation. Neurocysticercosis most commonly affects the brain parenchyma. Intraventricular cysticercal cysts are seen in 20-50% of cases- fourth ventricle being a common site followed by lateral ventricles and third ventricle which are relatively uncommon locations [1].

We present a case of intraventricular cysticercosis located in the atrium of lateral ventricle, a relatively uncommon location, causing asymmetric hydrocephalus.


   Case report Top


A 28 years old male presented with progressive holocranial headache associated with episodic vomiting and blurring of vision for 3 months. Clinical examination revealed signs of raised intracranial pressure without localization. Contrast enhanced CT (CECT) study revealed asymmetric dilatation of right lateral ventricle with a bulge was noted in the contour of right lateral ventricle at the level of atrium suggesting possibility of a space occupying lesion in the atrium with a midline shift of 11 mm to left [Figure - 1].

MRI using T1, T2 weighted standard spin echo sequences and FLAIR (Fluid Attenuating Inversion Recovery) sequence revealed asymmetric right lateral ventricular dilatation with midline shift to left. A cystic lesion in the atrium of right lateral ventricle was suggested by the bulge in the right ventricular contour at that site. Intensity of the lesion was same as that of CSF on all sequences. No well defined cyst rim or wall could be made out. Abnormally enhancing and mildly enlarged choroid plexus was seen in the right ventricle abutting the cyst [Figure - 2]. Based on these findings, a differential diagnosis of choroid plexus tumour with loculated hydrocephalus or intraventricular cyst (choroid plexus cyst /cysticercosis) was kept.

Patient underwent right parietal craniotomy whereby following corticectomy, right occipital horn was opened and a small membranous cystic structure with a solid component of about 5mm causing obstruction to foramen of monro was excised from the atrium. The foramen of monro was identified and there was no obstruction to it following cyst removal. Histopathological examination revealed a degenerated cysticercus parasite with a thick cuticle and scolex. Patient developed signs of raised intracranial pressure after one week and after his CT scan showed hydrocephalus a right ventriculoperitoneal shunt was placed. The patient was given albendazole for 3 months and he was relieved of his headache and other raised pressure symptoms and was doing well in his last follow up which was of 13 months.


   Discussion Top


Active Neurocysticercosis is classified according to the location into [2]:

  1. Parenchymal cysts.
  2. Ventricular cysts.
  3. Subarachnoid cysts.
  4. Cysticercus racemose.


Patients with intraventricular cysticercosis generally present with symptoms related to obstructive hydrocephalus. Aqueductal stenosis due to ependymal inflammation or adhesions caused by prior ventricular infection due to neurocysticercus is a common presentation [3]. Intraventricular cysts can be found in any compartment but tend to migrate to the fourth ventricle because of gravity and CSF flow patterns. By physically obstructing the CSF pathway, intraventricular cysts may cause a noncommunicating hydrocephalus. Alternatively, death of an intraventricular cyst may lead to ependymitis resulting in a communicating hydrocephalus. Acute intermittent hydrocephalus or sudden loss of consciousness (Brun's syndrome) may result if a mobile intraventricular cyst is present. A case of sudden death due to migration of a cyst from the wall of lateral ventricle to the foramina of monro has been reported [4]. Differential diagnosis of an intraventricular cyst includes choroid plexus cyst, ependymal cyst, colloid cyst, cysticercal cyst [5].A typical cysticercal cyst measures about 8-20 mm and surrounds an elongated structure, the scolex which is fixed at one end and measures 6x 3mm approximately. Various stages of evolution of a cyst can be differentiated by imaging [6].

Neuroimaging studies like CT and MRI have drastically improved the diagnostic accuracy of neurocysticercosis by providing objective evidence about the topography of the lesion and the degree of host inflammatory response against the parasite. Intraventricular lesions are isodense to CSF on CT and hence not well imaged [5] as was seen in our case. MRI is sensitive in the diagnosis of active neurocysticercosis and may be useful in evaluating degenerative changes in the parasite [2]. Intraventricular cysts are detected on MRI by mass effect, ventricular obstruction, detection of a cyst rim, and/ or CSF flow void adjacent to the rim. Intensity of cysts that are viable is similar to that of CSF on both T1 and T2 weighted images. In our case, although no cyst wall was detected, yet mass effect and asymmetric ventricular dilatation suggested the presence of a space occupying lesion of intensity paralleling that of CSF on all sequences i.e, a cystic lesion. Degenerated cysts show increased signal intensity on T1 weighted images presumably resulting from increased protein content. In our case, the cyst intensity paralleled that of CSF although pathologically degenerated cysticercus was seen. Pericystic high signal intensity is seen on both proton density and T2 weighted images and represents gliosis, edema and inflammation [3].

Ventricular cysts are treated with surgical removal. However, if pericystic enhancement is present, ventriculoperitoneal shunt should be performed and followed by albendazole. Definitive surgery in such cases has higher failure rate presumably due to associated ependymitis. The absence of gadolinium enhancement on MRI is an indication for excision of the lesion as surgery related failure rate is lower in these cases [7].

Inspite of higher sensitivity of MRI, there have been reports of missed intraventricular cysticercal cyst on routine MR sequences. In our case too, a definite diagnosis of cysticercosis could not be achieved on imaging due to non visualization of the cyst wall and scolex. 3 D -CISS(Constructive interference in steady state MR sequences) is a high resolution heavily T2 weighted sequence with millimeter thin sections , short TE and low flip angle originally used for assessment of temporal bone and cerebellopontine angle lesions. This sequence is highly sensitive in identifying features of a cysticercal cyst especially the scolex .Cyst wall and cyst fluid can also be identified in a majority of patients [6].

 
   References Top

1.Osborne AG. Diagnostic neuroradiology, ed. USA: Mosby yearbook, Inc. 1994: 709- 710.  Back to cited text no. 1    
2.Martinez HR, Rangel-Guerra R, Arrendondo-Estrada JH, Marfil A, Onofre J. Medical and surgical treatment in neurocysticercosis: A MR study in 161 cases. J Neurol Sci 1995 May; 130(1): 25-34.  Back to cited text no. 2    
3.Teitulbaum GP, Otto RJ, Lin M, Manz HJ , Bradley WG Jr. MR imaging of neurocysticercosis. Am J Roengenol 1989 Oct; 153(4): 857-866.  Back to cited text no. 3    
4.Hawk MW, Shahlaie K, Kim KD, Theis JH. Neurocysticercosis: a review. Surgical Neurology 2005; 63: 123-132.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Khandelwal S, Sakhi P, Sharma GL, Saxena UD. Intraventricular cysticercosis. Ind J Radiol Imaging 2002; 12:3:329-332.  Back to cited text no. 5    
6.Govindappa SS, Narayanan JP, Krishnamoorthy VM, Shastry CH, Balasubramaniam A, Krishna SS. Improved detection of intraventricular cysticercal cysts with the use of 3D constructive interference in SSMR sequences. Am J Neuroradiol 2000 Apr; 21(4): 679-684.  Back to cited text no. 6    
7.Citow JS, Johnson JP, Mc Bride DQ, Ammirati M. Imaging features and surgery related outcomes in intraventricular neurocysticercosis . Neurosurg Focus 2002 Jun 15; 12(6): e6.  Back to cited text no. 7    

Top
Correspondence Address:
S Kalra
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, U.P
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32345

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