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CASE REPORT |
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Year : 2014 | Volume
: 7
| Issue : 4 | Page : 519-521 |
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Intraventricular cysticercal cyst
Amit Agrawal, G Malleswara Rao
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
Date of Web Publication | 25-Jun-2014 |
Correspondence Address: Amit Agrawal Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.135297
Due to the risk of acute obstructive hydrocephalus and mortality, intraventricular cysticercosis has been considered as a potentially life-threatening emergency that needs an early diagnosis and urgent intervention. In the present article, we discuss the imaging findings in a case of intraventricular cysticercal cyst. Surgical removal of ventricular cysts and establishment of the normal cerebrospinal fluid (CSF) pathway is the mainstay of treatment, which can be best achieved by neuroendoscopy. Keywords: Cysticercus cyst, hydrocephalus, intraventricular, lateral ventricular cyst, magnetic resonance imaging
How to cite this article: Agrawal A, Rao G M. Intraventricular cysticercal cyst. Med J DY Patil Univ 2014;7:519-21 |
Introduction | | |
Neurocysticercosis is caused by the larval form of the pork intestinal tapeworm, Taenia solium, and there is central nervous system (CNS) involvement in 60-90% of the infested patients. [1] Neurocysticercosis commonly involves the brain parenchyma, and intraventricular cysticercal cysts are seen in up to 20-50% of cases. [1] Due to the risk of acute obstructive hydrocephalus and mortality, intraventricular cysticercosis has been considered as a potentially life-threatening emergency that needs an early diagnosis and urgent intervention. [2],[3],[4] In the present article, we discuss the imaging findings in a case of intraventicular cysticercal cyst.
Case Report | | |
A 16-year-old male child presented with the history of headache of 3 months duration. The headache became worse over the last 4-5 days and was associated with vomiting. One day before, he lapsed into altered sensorium. He had abnormal posturing of the body and high-grade fever. There was no past history of fever or seizures. At the time of presentation, the patient was in altered sensorium (GCS-E1V1M2), and the pupils were bilaterally constricted and reacting to light. He had fever of 101°F. Other general and systemic examination was unremarkable. The patient underwent urgent computed tomography (CT) scan brain and it showed asymmetrical dilatation of the lateral ventricles (left more than right), shift of septum pellucidum to the right, and an isodense rim in the left lateral ventricle [Figure 1]a. Magnetic resonance imaging (MRI) brain T1-weighted (T1W) image showed a well-defined ring-shaped lesion in the left lateral ventricle. The ring was isointense with an area of hyperintensity. The lesion was becoming hyperintense on T2-weighted (T2W) images and the hyperintense region was becoming isointense; on fluid-attenuated inversion recovery (FLAIR) images, the lesion was isointense to CSF and the ring was better visualized [Figure 1]a-f. The patient underwent endoscopic removal of the cyst and placement of external ventricular drain. Follow-up CT scan showed a decrease in the size of the ventricles and removal of the cyst [Figure 2]. The extraventricular drain was removed on the 4 th day. The patient received a course of albendazole. | Figure 1: (a) CT scan brain plain showing asymmetrical dilatation of the lateral ventricles (left more than right), shift of septum pellucidum to the right, and an isodense rim in the left lateral ventricle. (b) MRI brain T1W image showing well-defined ring-shaped lesion in the left lateral ventricle; the ring is isointense with an area of hyperintensity. (c) The lesion is becoming hyperintense on T2W images and the hyperintense region has become isointense now. (d) On FLAIR, the lesion is isointense to CSF and the ring is better visualized. (e) No restrction on diffusion sequence and (f) corresponding ADC image showing iso-intense scolex
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| Figure 2: Postoperative CT scan showing resolution of the hydrocephalus (External ventricular drainage was clamped) and excision of the cyst
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Discussion | | |
The patients with intraventricular cysticercosis present with acute obstructive hydrocephalus and associated features, i.e. headache, vomiting, and altered sensorium. [2],[3],[4],[5] With the advancements in neuroimaging techniques, not only the diagnosis of these lesions has improved drastically but also it is possible to anticipate the accuracy about the diagnosis of neurocysticercosis by providing objective evidence on imaging. [5] On CT scan, the intraventricular lesions are isodense to CSF, and hence, it is difficult to visualize these lesions on CT alone. [6] MRI with cerebrospinal fluid (CSF) flow studies has been shown to be superior to CT alone as it permits demonstration of cystic lesions in greater detail. [7] On MRI, an intraventricular cyst can be suspected because of mass effect, ventricular obstruction, detection of a cyst rim, and/or CSF flow void adjacent to the rim. [5] Intraventricular cysticercal lesions produce signal intensities similar to those of CSF on both T1W and T2W images and may not be demonstrable on routine MR sequences. [5],[8] On T1W images, the cysts are generally isointense to CSF and on T2W, they are isointense or hyperintense to CSF and the cyst wall and nodule (scolex) can also be seen in some patients. [8] As in the present case [Figure 1]d, MR FLAIR images can very well outline the cyst wall and the nodule. [8],[9],[10],[11] A number of cystic lesions including choroid plexus cyst, ependymal cyst, and colloid cyst need to be considered in the differential diagnosis of an intraventricular cyst. [6] Role of medical therapy is controversial; however, in cases of larger lesions or residual disease, a course of single (albendazole) or combined (albendazole + praziquantel) cysticidal drugs may be needed. [3],[12] Intraventricular cysticercosis has been recognized as one of the favorable forms of neurocysticercosis where a surgical excision is possible. [2],[3] Surgical removal of ventricular cysts and establishment of the normal CSF pathway is the mainstay of treatment, which can be best achieved by neuroendoscopy. [13] It is of utmost importance that the cysts in the third ventricle need to be removed without causing rupture. [3]
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[Figure 1], [Figure 2]
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