
Neuroradiology
Case TypeClinical Case
Authors
Sandra López Coello, Nicolás Ochoa Sambrizzi, Maria José Capponi, Ángel Sánchez-Montañez, Juan Carlos Tortajada Bustelo
Patient64 years, female
A 64-year-old female patient with no relevant previous medical history attended the emergency room (ER) after a 3-day episode of disorientation, mental gaps, and symmetrical paresis of both lower extremities associated with frequent falls. No fever, dyspnoea, or other symptomatology was reported.
A non-contrast-enhanced brain CT revealed a global dilation of the ventricular system associated with transependymal oedema, suggesting acute hydrocephalus. An ill-defined heterogeneous lesion was observed at the floor of the IV ventricle.
Brain MRI revealed a focal lesion with a heterogeneous signal and a solid-multicystic appearance occupying the IV ventricle, leading to its obliteration with marked widening. Hyperintense focal areas in T1-weighted images suggestive of proteinaceous-cystic content were observed, and there was no evidence of diffusion restriction. Following intravenous contrast administration, peripheral patchy enhancement was observed. The perfusion sequence did not show areas of increased cerebral blood volume.
Diagnosis of neurocysticercosis was suggested, being metastasis or primary tumour less likely. An urgent external ventricular drain was placed, followed by scheduled surgical excision of the lesion and insertion of a ventriculoperitoneal shunt. The lesion exhibited proteinaceous, serous and solid components. Pathological analysis confirmed cysticercosis, and treatment with albendazole and praziquantel was initiated.
Background
Neurocysticercosis is considered the most frequent helminthic disease of the central nervous system, caused by the ingestion of Taenia solium’s eggs through faecal-oral transmission. Taenia solium may cause disease through any of three main mechanisms: the presence of the parasite itself (mass effect, obstruction), the subsequent inflammatory response (oedema), and residual scarring (fibrosis, granulomas, and calcifications) [1].
Clinical Perspective
Neurocysticercosis has different clinical presentations and depends on the number, location, size, and stage of the parasites, as well as the degree of the host’s inflammatory response. Seizures are the most common clinical manifestation (70% of patients), followed by headaches and those symptoms caused by cerebrospinal fluid (CSF) obstruction [2].
Neurocysticercosis in the fourth ventricle can lead to Bruns syndrome, characterised by headaches, papilledema, and possible unconsciousness, with swift recovery upon head rotation [3].
Imaging Perspective
Neurocysticercosis exhibits various developmental stages, which can be distinguished through imaging:
A key radiological indicator is the presence of the scolex, the tapeworm’s anterior end with hooks and suckers, seen as bright nodules measuring 2 to 4 millimetres within the cyst’s cavity [2,4].
While interpreting radiological images, it is crucial to meticulously assess for accompanying phenomena resulting from cystic mass effect and surrounding oedema, arteritis possibly leading to infarction, arachnoiditis, and potential ventricular involvement [2].
Outcome
IV ventricle neurocysticercosis presenting with acute hydrocephalus is a rare but important clinical entity that requires timely recognition and intervention. Patients displaying viable or degenerating cysts in brain imaging warrant antiparasitic therapy. However, when viable cysts lead to obstruction, definitive treatment involves the neuroendoscopic removal of the cysts.
Take Home Message / Teaching Points
Not every mass in the IV ventricle is of tumoural origin, and non-tumoural lesions such as cysticercosis should always be considered in the differential diagnosis.
[1] Carpio A, Romo ML, Parkhouse RM, Short B, Dua T (2016) Parasitic diseases of the central nervous system: lessons for clinicians and policy makers. Expert Rev Neurother 16(4):401-14. doi: 10.1586/14737175.2016.1155454. (PMID: 26894629)
[2] Kimura-Hayama ET, Higuera JA, Corona-Cedillo R, Chávez-Macías L, Perochena A, Quiroz-Rojas LY, Rodríguez-Carbajal J, Criales JL (2010) Neurocysticercosis: radiologic-pathologic correlation. Radiographics 30(6):1705-19. doi: 10.1148/rg.306105522. (PMID: 21071384)
[3] Roque D, Hipólito-Reis J, Duarte-Batista P, Manuel Santos M (2021) Fourth ventricle neurocysticercosis presenting with Bruns' syndrome: A case report. Surg Neurol Int 12:616. doi: 10.25259/SNI_1091_2021. (PMID: 34992932)
[4] Perez A, Syngal G, Fathima S, Laali S, Shamim S (2022) Intraventricular neurocysticercosis causing obstructing hydrocephalus. Proc (Bayl Univ Med Cent) 35(5):722-4. doi: 10.1080/08998280.2022.2075669. (PMID: 35991743)
URL: | https://eurorad.org/case/18503 |
DOI: | 10.35100/eurorad/case.18503 |
ISSN: | 1563-4086 |
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