A case-based review on the neuroendoscopic management of intraventricular and subarachnoid basal neurocysticercosis.

OBJECTIVE: Extraparenchymal localization of neurocysticercosis (NCC) is rare in non-endemic areas. A case of mixed (intraventricular, IV, and subarachnoid basal, SAB) NCC was surgically treated using the neuroendoscope and a systematic review of the literature was performed with the aim to analyze the use of this instrument in the management of the extraparenchymal forms of the parasitic disease. MATERIALS AND METHODS: Medline and Embase databases were searched for studies where the neuroendoscope was used for the management of IV/SAB NCC cysts, either for the cerebrospinal fluid diversion or cyst removal. Cyst location, complete removal, cyst breakage during removal, intraoperative and postoperative complications, administration of antihelmintic therapy, outcome and follow-up period were extracted from the articles. RESULTS: 281 patients were treated by means of the neuroendoscope. 254 patients who were described in retrospective cohort studies, came all from endemic areas, with no significant difference between sexes. Mean age at surgery was 30.7 years. Of all cysts reported in retrospective studies, 37.9% were located in the fourth ventricle. An attempt of cyst removal was described in the 84.6% of cases and an endoscopic third ventriculostomy was performed in another 76.4%. A small number of complications were reported intraoperatively (9.1%) obtaining, but a good recovery was achieved at follow-up. Only 17 ventriculoperitoneal shunts were placed after the first procedure, defining a low risk of postoperative hydrocephalus even in case of partial cyst removal. CONCLUSION: Neuroendoscopic removal of an extraparenchymal NCC cyst is a safe procedure that should be preferred for lateral and third ventricle localization and, in a specialized centre, even for a localization in the fourth ventricle if feasible. It is also efficient because of the possibility of performing an internal CSF diversion concomitantly to cyst removal, avoiding the complication registered with VPS. The need for cysticidal treatment after surgery should be addressed in a prospective study.

Postsurgical Outcomes of Mesial Temporal Lobe Epilepsy due to Hippocampal Sclerosis Associated with Calcified Neurocysticercosis.

The aim of this study was to analyze postsurgical outcomes for individuals with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) who underwent anterior temporal lobectomy, based on the presence of calcified neurocysticercosis (cNCC). A retrospective cross-sectional study was conducted on 89 patients with MTLE-HS who underwent anterior temporal lobectomy between January 2012 and December 2020 at a basic epilepsy surgery center located in Lima, Peru. We collected sociodemographic, clinical, and diagnostic information. The postsurgical results were analyzed using bivariate analysis according to the Engel classification. We included 89 individuals with a median age of 28 years (interquartile range [IQR]: 24-37), and more than half (55.1%) were male. Seventeen (19.1%) were diagnosed with cNCC. A greater number of patients with cNCC had lived in rural areas of Peru during their early life compared with those without cNCC (12 [70.6%] versus 26 [36.1%]; P = 0.010). Patients with cNCC exhibited a greater median frequency of focal to bilateral tonic-clonic seizures per month (1 [IQR: 0-2] versus 0 [0-0.5]; P = 0.009). Conversely, a lower proportion of patients with cNCC reported a history of an initial precipitating injury in comparison to the group without cNCC (4 [23.5%] versus 42 [58.3%]; P = 0.014). At the 1-year follow-up, most patients (82.4%) with cNCC were categorized as Engel IA. Similarly, at the 2-year follow-up, nine (75.0%) were classified as Engel IA. Our findings suggest that most patients diagnosed with cNCC exhibit favorable postsurgical outcomes, comparable to those without cNCC. Additionally, it can be postulated that cNCC may play a role as an initial precipitating injury.

Is Antihelminthics Necessary in Postoperative Treatment of Intraventricular Neurocysticercosis? A Systematic Review.

OBJECTIVE: Patients with intraventricular neurocysticercosis (IVNCC) may require cerebrospinal fluid diversion surgery for late-onset hydrocephalus in the postsurgical period. Controversy exists regarding cysticidal treatment. Our main objective was to compare surgically treated cases of IVNCC that received postoperative anthelmintics with those that did not regard the incidence and treatment of late-onset hydrocephalus. METHODS: We searched the Medline database and extracted the following data: age, gender, stage of development of cysticercosis, type of operation, frequency of delayed hydrocephalus, cerebrospinal fluid diversion surgery, outcome, and follow-up. RESULTS: We analyzed 130 articles on intraventricular cysticercosis and identified 117 cases of isolated IVNCC and 314 patients in the case-control series who met inclusion criteria. There was no significant difference in postoperative delayed hydrocephalus between isolated IVNCC and case-control study groups. Children under the age of 16 received anthelmintic drugs more frequently during the postoperative period. Statistical relevance was observed in all patient groups regarding the application of steroids in favor of cysticidal therapy Endoscopy was a better option than craniotomy for cases of isolated IVNCC and case-control studies. Other variables were not relevant. CONCLUSIONS: Patients who received antihelminths did not show a statistically significant reduction in delayed hydrocephalus compared to individuals who did not receive after surgical resection of the parasite. Corticosteroid therapy prevailed in people who have been treated with anthelmintics. Children under the age of 16 were administered anthelmintic drugs more frequently during the postoperative period. Endoscopy was the preferred method for all groups, but some patients with cysts in the fourth ventricle required a craniotomy.

Intraventricular migration of fourth ventricular neurocysticercosis: an unusual complication during endoscopic surgery.

A boy in his middle childhood presented with intermittent episodes of headache with vomiting for 6 months. Plain CT of the head and MRI of the brain revealed fourth ventricular cysticercal cyst with acute obstructive hydrocephalus. Endoscopic excision of the cyst was done along with endoscopic third ventriculostomy and septostomy with external ventricular drain placement. Although we were able to decompress the cysticercal cyst, unfortunately, the cyst got slipped from the grasper leaving the grasped cyst wall in the tooth of the grasper. Through this case report, we want to highlight that such a complication could also happen during neuroendoscopic cysticercal cyst removal and how we dealt with it. Our patient was discharged neurologically intact and was symptom free on follow-up.

Isolated Intraventricular Neurocysticercosis: Atypical Presentation of a Colloid Cyst.

Neurocysticercosis is a condition characterized by the presence of Taenia solium (larval stage: Cysticercus cellulosae) in the brain and is classified as a tropical disease. Although it was previously uncommon in Europe, the number of cases has been increasing over the past decade. In this report, we present a case of a patient who was admitted with symptoms of raised intracranial pressure and biventricular hydrocephalus, without evidence of infection. Imaging studies revealed the presence of an atypical colloid cyst, which was subsequently removed using a neurosurgical endoscopic approach. Anatomopathologic analysis confirmed the presence of a C. cellulosae larva. It is crucial not to overlook or misdiagnose isolated intraventricular neurocysticercosis because it can lead to complications such as delayed diagnosis and dissemination of the cyst.

Neurocysticercosis and hydrocephalus: the value of ventriculoperitoneal shunting in its management.

BACKGROUND: Hydrocephalus is the main complication of extraparenchymal neurocysticercosis (EP-NC). Its symptomatic management relies mainly on the placement of a ventriculoperitoneal shunt (VPS). Previous studies have shown that this surgical procedure is associated with a poor prognosis, but current information is lacking. METHODS: We included 108 patients with a definitive diagnosis of EP-NC and hydrocephalus requiring VPS placement. We evaluated their demographic, clinical, and inflammatory characteristics, as well as the frequency of complications related to VPS placement. RESULTS: Hydrocephalus was present at the time of NC diagnosis in 79.6% of patients. VPS dysfunction occurred in 48 patients (44.4%), mainly within the first year after placement (66.7%). The dysfunctions were not associated with the location of the cyst, the inflammatory characteristics of the cerebrospinal fluid or the administration of cysticidal treatment. They were significantly more frequent in patients in whom the decision to place a VPS was made in the emergency department. Two years after VPS, patients' Karnofsky score averaged 84.6±15 and only one patient died of a cause directly related to VPS. CONCLUSIONS: This study confirmed the utility of VPS and showed a significant improvement in the prognosis of patients requiring VPS compared with previous studies.

Neurocysticercosis: challenges in pediatric neurosurgery practice.

PURPOSE: Neurocysticercosis (NCC) is considered a neglected infectious disease, but the most common parasitic disease of the central nervous system (CNS). Due to oral tendencies in childhood, it is hypothesized that individuals are infected around this age and develop symptoms as lately as during young adulthood. Although it is considered a benign disease, it may cause great impact in the patient's quality of life due to epilepsy, visual symptoms, and hydrocephalus, which eventually requires frequent hospitalizations. The treatment of hydrocephalus is the main challenge for neurosurgeons. METHODS: We performed a concise review on neurocysticercosis in children and the main presentations of NCC in the neurosurgery practice and a systematic review on hydrocephalus secondary to extraparenchymal NCC. RESULTS: Our review showed a rate of complete resolution of hydrocephalus secondary to NCC of around 80% with the first attempt of surgical treatment combined with medication therapy. Endoscopic removal of the intraventricular cysts with third ventriculostomy was the most common treatment modality. Patients previously managed with ventricular shunts are likely to have worse outcomes and complications. CONCLUSION: Endoscopic approach is the gold standard surgical treatment for hydrocephalus secondary to neurocysticercosis.

Racemose Fourth Ventricle Neurocysticercosis Excision Through Telovelar Approach and Hydrodissection.

Intraventricular neurocysticercosis is associated with more severe complications and a worse overall outcome.1,2 Fourth ventricle neurocysticercosis (FVNCC) often presents with cerebrospinal fluid obstruction and hydrocephalus by means of direct mechanical occlusion of ventricular outlets by the cysts or due to an ependymal inflammatory response. Unfortunately, there is little consensus on the optimal management for FVNCC. If possible, surgical removal of cysticerci rather than medical therapy and/or shunt surgery is recommended.3 Endoscopic removal of cysts is described to be an effective treatment modality.4 However, endoscopic removal of inflamed or adherent ventricular cysticerci is associated with increased risk of complications.5 Although microdissection through a posterior fossa telovelar approach is a valid method for FVNCC,6,7 scarce reports describe the therapeutic decision making and provide a surgical video of adherent FVNCC cyst resection. Video 1 shows a 40-year-old female born in Honduras who presented with progressive headache. Computed tomography revealed ventriculomegaly and transependymal flow. Magnetic resonance imaging demonstrated obstructive hydrocephalus secondary to a multiloculated cystic mass within the fourth ventricle. According to the diagnostic criteria, probable racemose FVNCC was suspected.8 Magnetic resonance imaging raised suspicion that the cysts could be densely adherent to surrounding structures,9 precluding endoscopic removal. We performed a combined microscopic and endoscopic approach, which permitted removal of the cysts through a telovelar approach and hydrodissection technique without damaging nearby structures and treatment of the associated hydrocephalus through an endoscopic third ventriculostomy, allowing complete resolution of symptoms and avoidance of cerebrospinal fluid shunting.

Single Burr-Hole Extended Transforaminal Approach for Concurrent Endoscopic Surgery in the Third Ventricle Posterior to the Foramen of Monro and Ventriculostomy: Clinical Series and Planning Steps.

OBJECTIVE: For endoscopic surgery of third ventricular lesions posterior to the foramen of Monro that frequently require a third ventriculostomy during the same procedure, the extended transforaminal approach (ETFA) through the choroid fissure has been proposed. This study reports clinical results and provides anatomic background and guidelines for individual planning of a single burr-hole approach and a safe transchoroid entry zone. METHODS: A retrospective review was undertaken of 25 cases of concurrent third ventricle surgery and third ventriculostomy via ETFA. Assessment was made of a safe transchoroidal entry zone on cadavers (6 hemispheres) and of planning guidelines on magnetic resonance imaging showing occlusive hydrocephalus (30 sides). RESULTS: ETFA was feasible in all 25 cases. The safe transchoroid entry zone was sufficient in 16 cases; in 9 cases, additional transchoroid opening with transection of the anterior septal vein was required without clinical consequences. The anatomic study showed a safe transchoroid entry zone of 5 mm (3-6 mm) for posterior enlargement of the foramen of Monro. Individual planning on magnetic resonance imaging of patients with enlarged third ventricles showed an optimal burr-hole position 22 mm (10-30 mm) lateral to the midline and 8 mm (27 to -23 mm) precoronal; a foramen of Monro diameter of 7 mm (3-11 mm) and a safe transchoroid entry zone of 6 mm (3-12 mm). CONCLUSIONS: According to our data, concurrent endoscopic surgery of third ventricular lesions posterior to the foramen of Monro and ventriculostomy are feasible through a single burr hole and a transchoroid extension of the transforaminal approach. Precise preoperative planning is recommended for anticipating the individual anatomic nuances.

Post-Infective Hydrocephalus.

BACKGROUND: Post-infective hydrocephalus (PIH) arises as a complication of any CNS infection, and can be either communicating or noncommunicating. OBJECTIVE: The aim of this article is to study the various causes of PIH and its pathophysiology and treatment. MATERIAL AND METHODS: The literature was searched for articles describing the causes of PIH. RESULTS: Common causes of PIH are CNS tuberculosis (TB), neurocysticercosis, and perinatal or neonatal infection. TBM is most likely to result in hydrocephalus out of all these manifestations of CNS TB, and hydrocephalus is more likely to occur early in the course, typically 4-6 weeks after the onset of TBM, and is more common among children as compared to adults. A trial of medical management (antitubercular therapy, steroids, and decongestants) can be given to patients with communicating hydrocephalus. Ventriculoperitoneal shunt is the most employed method of CSF diversion in these patients. Though traditionally considered contraindicated, many recent studies have found ETV to be a reasonable option in patients with PIH. HCP in patients with neurocysticercosis can be associated with intraventricular cysts and racemose cysts in the basal subarachnoid cisterns. Surgical intervention is required either for cyst removal or CSF diversion. Endoscopic approaches can be used to remove the intraventricular cysts, which takes care of the HCP. PIH in infants can result either from antenatal infections (TORCH infections) or postnatal infections such as meningitis. CONCLUSIONS: Management of PIH can be challenging. Management has to be individualized.

Endoscopic intervention for intraventricular neurocysticercal cyst: Challenges and outcome analysis from a single institute experience.

OBJECTIVE: Endoscopic intervention is presently proposed as standard approach for the treatment of Intraventricular neurocysticercal cyst (IVNCC) as it helps to retrieve the cyst as well as CSF diversion. We present our series of 61 patients with IVNCC managed by endoscopic intervention and analyze the outcome. METHOD: A retrospective analysis of 61 patients with IVNCC managed between 1998-2019 at our institute was performed. We reviewed the clinical details of consecutive patients, management, and outcome. RESULTS: There were 61 patients with 34 males and 27 females. The mean age was 25 years. Fourth ventricular location is the most common (n = 34) followed by third ventricle(n = 14) and lateral ventricle (n = 13). Cyst retrieval could be done in 43 cases, while the cyst could not be retrieved in 18 cases due to intraventricular bleed, CSF turbidity, adhesion of cyst wall etc. Along with cyst retrieval, some patients underwent Endoscopic Third ventriculostomy, septostomy, foraminotomy for internal CSF diversion. Seven patients had a preoperative VP shunt surgery. The median follow-up was 12 months. Preoperative shunt (CI:1.33-62, P = 0.02) was associated with failure of cyst retrieval in univariate analysis as well as in multivariate regression analysis (CI: 0.02-0.94, P = 0.04). Two patients underwent shunt surgery at follow-up period due to the failure of endoscopic CSF diversion. CONCLUSION: Endoscopic management of IVNCC is a safe and effective management option, avoiding an indwelling shunt system. Endoscopic third ventriculostomy should be considered for patients with IVNCC and hydrocephalus.

Hemifacial Spasm Secondary to Arachnoiditis Due to Neurocysticercosis: Clinical Image.

Subarachnoid neurocysticercosis (NCC) is a form of NCC with cysticerci located in the subarachnoid space. This form of NCC can cause general and focal neurologic symptoms, and sometimes requires surgical intervention as a treatment. In this report, we present a rare case of hemifacial spasm secondary to arachnoiditis because of an NCC cyst in the cerebellopontine angle. The cysticercus was removed and the facial nerve was liberated via a retrosigmoidal approach. At 8-month follow-up, the patient reported no recurrence of symptoms. To our knowledge, this is the first case reported to surgically manage hemifacial spasm secondary to NCC arachnoiditis.

Neurocysticercosis Presenting as an Isolated Suprasellar Lesion.

BACKGROUND: Although extraparenchymal neurocysticercosis (NCC) is well established, presentation in the suprasellar space is rare. When presenting in the suprasellar space, the imaging characteristics may mimic more common lesions including craniopharyngioma and Rathke cleft cyst depending on the life cycle of the parasite. Although antiparasitic medical therapy may be effective for viable NCC, it is not routinely employed for calcified NCC. CASE DESCRIPTION: This report presents a 39-year-old male patient who presented with profound visual decline secondary to a partially calcified suprasellar NCC. Suprasellar NCC was presumed based on specific radiologic findings, which are discussed. Medical therapy was not offered because of the proximity to the optic chiasm and the partial calcification of the lesion leading to the presumption that the mass was nonviable. The patient underwent successful endoscopic endonasal resection of the suprasellar NCC and experienced significant improvement in vision. Despite the calcification, pathological evaluation revealed that a portion remained viable. CONCLUSIONS: Regardless of the life cycle stage, endonasal resection offers a minimally invasive approach for suprasellar NCC; treatment can be tailored to the patient's presentation and stage of infection.

Bruns Syndrome Caused by Intraventricular Neurocysticercosis: Literature Review

Bruns syndrome is one of the clinical presentations of intraventricular neurocysticercosis, and it is characterized by episodes of headache, vertigo and vomiting. The intraventricular form of neurocysticercosis occurs in 7% to 20% of the cases, and it is more serious than the intraparenchymal form. The management is primarily surgical, associated with pharmacological therapy with anthelmintic drugs and corticosteroids. We report the case of a patient who presented Bruns syndrome due to neurocysticercosis.

The rolling cyst: migrating intraventricular neurocysticercosis-a case-based update.

BACKGROUND: Neurocysticercosis is the most frequent parasitic disease of the central nervous system, and its incidence in the developed countries is increasing due to immigration and travels from endemic areas. The intraventricular location has been found to involve up to 61.3% of the patients; moreover, only 22 cases of migrating intraventricular cyst have been reported so far. Despite the rarity of the condition in western countries, its occurrence generates some concerns and the aim of this paper is to update the information concerning pathogenesis, clinical presentation, diagnosis and management of this entity. METHODS AND RESULTS: All the pertinent literature was analysed, focused on the cases of migrating intraventricular neurocysticercosis and its peculiar features. An illustrative case regarding a 14-year-old girl is also presented. CONCLUSIONS: Migrating intraventricular neurocysticercosis is a pathognomonic entity usually presenting with hydrocephalus, and its treatment is mainly surgical, preferring an endoscopic approach. When the resection of the intraventricular cyst is not performed, an accurate follow-up is mandatory to detect clinical changes due to a recurrent hydrocephalus or to the effect of the dying cyst on the surrounding area. In case of permanent shunt placement, the cysticidal and steroid treatment is recommended to reduce the risk of shunt failure.

Microsurgical Treatment of Epilepsy with Parenchymal Neurocysticercosis.

Parenchymal neurocysticercosis is the most common form of neurocysticercosis in the central nervous system (CNS), which mainly causes epilepsy and usually responses well to routine medications. However, there are appreciable cases of relapses refractory to medical treatment. We investigated microsurgical treatment of epilepsy with parenchymal neurocysticercosis. Nine cases of epilepsy caused by parenchymal neurocysticercosis from 2002 to 2018 were analyzed retrospectively. Cysts in 7 cases were completely removed. No case died of operation and no new dysfunction of the nervous system was observed after surgery. Among the other 9 cases, 8 cases became seizure-free or controlled by medicine according to the postoperative follow-up for 6 months to 9 years. One case was lost for follow-up. It was suggested that epilepsy with parenchymal neurocysticercosis can usually be controlled after routine medications. However, surgery is still indicated in some cases and careful microsurgery is associated with satisfactory clinical outcomes in appropriately selected cases.

Neurocisticercosis racemosa gigante resistente al tratamiento farmacológico convencional. Reporte de un caso clínico y revisión de la literatura / Giant Racemose Neurocysticercosis Resistant to Conventional Pharmacological Treatment. Case Report and Literature Review / Neurocisticercose racemosa gigante resistente ao tratamento farmacológico convencional. Relatório de um caso clínico e revisão da literatura

Resumen: La teniosis/cisticercosis es una enfermedad parasitaria causada por la infección del estado larvario de Taenia solium. La Organización Mundial de la Salud (OMS) considera esta patología un problema de salud pública, así como una infección olvidada. Las manifestaciones pueden variar según el tipo de presentación de la lesión, requiere manejo farmacológico en la mayoría de los casos e incluso puede llegar a requerir tratamiento quirúrgico, en algunas condiciones específicas. Se han reportado casos de resistencia del parásito al manejo con cisticidas, reportes en los cuales la ivermectina, antiparasitario de uso veterinario, se convierte en una importante opción de manejo. Para esta disertación, se presenta un caso de neurocisticercosis racemosa gigante, que requirió manejo quirúrgico en el cual se evidencia persistencia de las lesiones luego del tratamiento con cisticidas, el cual presentó mejoría con el manejo con albendazol de marca, en combinación con ivermectina.

Abstract: Taeniasis/cysticercosis is a parasitic disease caused by Taenia solium larval stage infection. The World Health Organization (WHO) considers this pathology a public health problem, as well as a neglected infectious disease. Its manifestations may vary according to the type of lesion, needs pharmacological management in most cases, and even requires surgical treatment in some specific conditions. Cases of parasite resistance to cysticides have been reported, in which ivermectin, an antiparasitic drug for veterinary use, has become an important treatment option. This paper presents a case of giant racemose neurocysticercosis that required surgical management because of persistent lesions after treatment with cysticides, which showed improvement with branded albendazole in combination with ivermectin.

Resumo: A teniose/cisticercose é uma doença parasitária causada pela infecção do estágio larval da Taenia solium. A Organização Mundial da Saúde (OMS) considera essa patologia um problema de saúde pública e uma infecção esquecida. As manifestações podem variar de acordo com o tipo de apresentação da lesão, que requer um tratamento farmacológico, na maioria dos casos, e pode até exigir tratamento cirúrgico, em alguns casos específicos. Foram relatados casos de resistência do parasita ao tratamento com cisticidas, relatórios nos quais a ivermectina, um antiparasitário para uso veterinário, torna-se uma importante opção de tratamento. Para esta dissertação, um caso de neurocisticercose racemose gigante é apresentado. Esse caso exigiu um tratamento cirúrgico, no qual a persistência das lesões após o tratamento com cisticidas foi evidente, mas mostrou melhoras após o tratamento com o albendazol e ivermectina.

[Clinical features and efficacy of microsurgery for treatment of cerebral cysticercosis of the fourth ventricle: a report of 24 patients].

OBJECTIVE: To analyze the clinical characteristics of 24 patients with cysticercosis of the fourth ventricle, and to evaluate the therapeutic efficacy of microsurgery. METHODS: The clinical data of 24 patients with cysticercosis of the fourth ventricle referred the Department of Neurosurgery of the Affiliated Hospital of Qinghai University from January 2000 to December 2018 were collected, and the clinical features, imaging characteristics, surgical methods, therapeutic efficacy and postoperative complications were analyzed. RESULTS: The 24 patients included 15 men and 9 women, and had a mean age of 43.5 years (range, 16 to 68 years). Preoperative imaging examinations showed obvious dilatation of bilateral lateral ventricles, the third ventricle and middle cerebral aqueduct, and spherical or cystic dilatation of the fourth ventricle. There were 18 cases positive for antibodies against cysticercus, and 3 of the 21 cases were egg positives. All 24 cases received microsurgery, including 8 cases via the median aperture approach, 7 cases via the median aperture-cerebellar vermis approach, and 9 cases via the transcerebellomedullary fissure approach. There were 17 cases with complete delivery of vesicles, 5 cases with vesicle rupture and 2 cases with extraction of cystic fluid followed by separation and removal of cystic wall. All cases had obvious retraction of the ventricular system and disappearance of intracranial hypertension following surgery. There were 19 cases (79.17%) with well recovery, and 5 cases (20.83%) with aggravation or development of cerebellar ataxia, which recovered following treatment for 1 to 2 weeks. CONCLUSIONS: The transcerebellomedullary fissure approach is a safe and lowly invasive approach for the treatment of cysticercosis of the fourth ventricle.