Case 11375 Adult onset seizures in a patient with neurocysticercosis

Sohail Iqbal , Muhammad Asim Rana , Mureed Hussain , Souhyb Masri , Mohammed A T1 2 3 1

Al-Dabbagh , Mohammed A Cheema , Abdul Hameed , Ahmed F Mady , Emad El-din Al-Thamer1 1 3 2

, A-Aziz Al-Mosabihi 2 2

KING SAUD MEDICAL COMPLEX

Neuroradiology Section: 2013, Dec. 7 Published:

25 year(s), malePatient:

Authors' Institution

(1) Colchester General Hospital,

Colchester, CO4 5JL, England

Email: drsohailiqbal@yahoo.com

(2) King Saud Medical City,

Riyadh, Kingdom of Saudi Arabia

(3) Tameside General Hospital,

Ashton under Lyne, OL6 9RW, England

Clinical History

A young adult Indian man presented with increasing confusion and acute onset of tonic clonic

seizures followed by unconsciousness. He showed no signs of meningism with bilaterally equal and

reactive pupils. Laboratory findings depicted normal blood and cerebrospinal fluid (CSF) and

negative polymerase chain reaction for mycobacterium tuberculosis.

Imaging Findings

Initial non-enhanced computed tomography (NECT) brain showed multiple variable-sized,

wide-spread, well-defined, hypo-dense lesions with high density eccentric nodules and associated

hydrocephalus. Magnetic resonance imaging (MRI) was also performed the same day showing

hypo-intense lesions on T1W and FLAIR and hyper-intense on T2WI with a central nodule. Acute

moderate hydrocephalus was also visualized with transependimal

oedema. CSF drainage was done by Ventriculo-peritoneal (VP) shunt insertion along with medical

management with Albendazole. Follow-up CT confirmed decreased size of the lesions and

resolution of hydrocephalus. VP shunt placement associated oedema was seen at the operative site

as irregular hypo-dense area on CT examination.

Discussion

Neurocysticercosis is caused by infestation with Taenia solium - a tapeworm endemic in many parts

of the developing world. The disease burden is spreading to non-endemic areas because of

increasing migration. Humans are thought to be definite hosts in its life cycle, giving years of

thriving before final overpower by host defenses and ultimately calcification [1]. Ingested eggs in

undercooked pork meat or contaminated food lose their protective capsule in the stomach and turn

into larval cysts which cross the intestinal barrier and migrate via the vascular system to the brain,

muscle, eyes, spine (1-5% in adults) and other structures [2]. It is most common in patients in their

early 30s with equal gender distribution and 4-8% prevalence in general population [3].

Neurocysticercosis may involve ventricles, cisterns, sub-arachnoid space, spinal cord or the eyes in

10-20% along with parenchymal lesions especially at grey-white junction. Clinical manifestations

include seizures, hydrocephalus associated headaches, arteritis associated infarcts and strokes, cord

compression, intra-vitreal or sub-retinal cysticercosis, cysticercal encephalitis,

meningo-encephalitis, granulomatous meningitis and focal abscess or granulomas. Seizures and

headache are related to active disease [4] whereas calcified granulomas present as chronic epilepsy

[5]. Colloidal cysts cause recurrent seizures and are the most symptomatic and survive up to a year

[6]. Almost 80 % of infections are asymptomatic [7].

Contrast-enhanced CT or MRI can differentiate four stages of the disease entity as follows: I)

Vesicular - the viable larval cyst with identifiable scolex as an eccentric nodule, II) Colloidal -

enhancing cyst without a well defined scolex, III) Nodular/granular - an enhancing but degenerating

nodule and IV) a non-enhancing calcified granuloma. MRI is better for detecting intra-ventricular,

extra-parenchymal disease and visualizing the scolex within the cysticercus. CT examination is

better for detecting intra-cerebral calcifications.

Albendazole or praziquantel is the specific treatment used along with corticosteroids to reduce

cerebral oedema or vasculitis. Surgical excision is required in giant cysts or a cyst at a critical

location such as fourth ventricle, middle cerebral artery or optic chiasma along with

ventriculo-peritoneal (VP) shunting for hydrocephalus [8].

Prognosis is the best for patients in whom imaging studies normalize after treatment.

Neurocysticercosis is a leading cause of epilepsy in the developing world and is increasingly

prevalent in the developed countries. Better understanding of the mechanisms of neurocysticercosis

and the life cycle of T. solium is needed to develop appropriate intervention and prevention

programs.

Final Diagnosis

Adult onset seizures in a patient with neurocysticercosis

Differential Diagnosis List

Brain abscess , Vasculitis

Figures

Figure 1 Neurocysticercosis

Multiple low attenuation lesions with hyper-dense nodule in left frontal lobe. © Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: CT;

Procedure: Computer Applications-Detection, diagnosis; Special Focus: Cysts;

Multiple lesions with mild oedema in left hemisphere. © Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: CT;

Procedure: Computer Applications-Detection, diagnosis; Special Focus: Cysts;

Figure 2 Hydrocephalus

Mildly dilated ventricles with sub-ependymal oedema. Multiple small cystic lesions withcalcified mural nodules are also seen.

© Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: CT;

Procedure: Computer Applications-Detection, diagnosis; Special Focus: Cerebrospinal fluid;

T2W axial image showing a small high signal cystic lesion with low signal mural nodule inright frontal lobe. Incidental ventricular air secondary to recent shunt placement.

© Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: MR;

Procedure: Imaging sequences; Special Focus: Cerebrospinal fluid;

FLAIR image, CSF signal 3 scattered intracerebral cystic lesions with mild hydrocephalus © Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: MR;

Procedure: Imaging sequences; Special Focus: Cerebrospinal fluid;

Axial FLAIR image showing lesions and cerebral oedema bilaterally © Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: MR;

Procedure: Drainage; Special Focus: Oedema;

Figure 3 Neurocysticercosis cysts

Sagittal MR image with parieto-occipital lesions. © Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: MR;

Procedure: Imaging sequences; Special Focus: Cysts;

Axial T2W images scattered lesions and oedema in the frontal lobes © Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: MR;

Procedure: Imaging sequences; Special Focus: Cysts;

FLAIR image with bilateral hypo-intense lesions © Rana M A, King Saud Medical City, Riyadh, KSA

Area of Interest: Head and neck; Imaging Technique: MR;

Procedure: Imaging sequences; Special Focus: Cysts;

References

[1] Carpio A (2002) Neurocysticercosis: An update Lancet Infect Dis. 2: 751-62

[2] Singhi P (2011) Neurocysticercosis Ther Adv Neurol Disord. 4: 67-81

[3] Azad R, Gupta R K, Kumar S, Pandey C M, Prasad K N, Husain N, et al. (2003) Is

neurocysticercosis a risk factor in coexistent intracranial disease? An MRI based study J Neurol

Neurosurg Psychiatry 74: 359-61

[4] DeGiorgio CM, Houston I, Oviedo S, Sorvillo F (2002) Death associated with cysticercosis:

Report of three cases and review of the literature Neurosurg Focus. 12: 1-4

[5] Roman G, Sotelo J, Del Brutto O, Flisser A, Dumas M, Wadia N, et al (2000) A proposal to

declare neurocysticercosis an international reportable disease Bull WHO 78: 399-406

[6] Pal D K, Carpio A, Sander J W A S (2000) Neurocysticercosis and epilepsy in developing

countries J Neurol Neurosurg Psychiatry 68:137-143

[7] Carpio A, Santillan F, Leon P, Flores C, Hauser WA (1995) Is the course of neurocysticercosis

modified by treatment with antihelminthic agents? Arch Intern Med 155:1982-88

Citation

Sohail Iqbal , Muhammad Asim Rana , Mureed Hussain , Souhyb Masri , Mohammed A T1 2 3 1

Al-Dabbagh , Mohammed A Cheema , Abdul Hameed , Ahmed F Mady , Emad El-din Al-Thamer1 1 3 2

, A-Aziz Al-Mosabihi (2013, Dec. 7) 2 2

Adult onset seizures in a patient with neurocysticercosis {Online}URL: http://www.eurorad.org/case.php?id=11375