[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.

Intraventricular Neurocysticercosis: Experience and Long-Term Outcome from a Tertiary Referral Center in the United States.

Ventricular involvement in neurocysticercosis (NCC), a common serious manifestation of NCC, has distinct clinical presentations, complications, and treatments primarily because of partial or complete obstruction of the cerebrospinal fluid (CSF) flow by Taenia solium cysts. We review the clinical course, treatments, and long-term outcomes in 23 of 121 (19.0%) total NCC patients with ventricular cysts referred to the National Institutes of Health from 1985 to the October 2017. Patients had a median age of 31.8 (range: 22.4-52.6 years), were 60.9% male, diagnosed a median of 6.5 years (range: 0.17-16 years) after immigration, and were followed for a median of 3.6 years (range: 0.1-30.5 years). Other forms and manifestations of NCC were present in 73.9% (17/23). The fourth ventricle was involved in a majority (15/23, 65.2%) resulting in hydrocephalus (73.9%), ventriculitis, and periventricular edema (7/23, 30.4%). Cystectomy was accomplished in 60.9%, usually by removal of a fourth ventricular cyst through a suboccipital craniotomy. Nonresectable cysts were treated medically. Ventriculoperitoneal shunts were inserted in 43.5% (10/23) and failed in four, three from infection. Other complications included surgically induced injuries (4/23, 17.4%) and entrapment of a lateral ventricle (2/23, 8.7%). Despite a common severe early course, 90.9% (20/22) stabilized without recurrence, 15% (3/20) complained of mild-to-moderate neurological complaints, and 15% (3/20) were significantly disabled. Four patients who underwent removal of ventricular cysts without significant other NCC and who received with no cysticidal treatment became CSF cestode antigen negative without recurrence indicating that after successful extraction of cysts, additional cysticidal treatment may not be needed.

An Unusual Presentation of Neurocysticercosis: A Space-Occupying Lesion in the Fourth Ventricle Associated with Progressive Cognitive Decline.

We communicate a case of a middle-aged Brazilian patient with an unusual presentation of fourth ventricular neurocysticercosis: occurrence of two intraventricular cysts at different locations in the brain within 2 years and cognitive decline as the only neurological symptom. Neurocysticercosis was confirmed by magnetic resonance imaging, serology, histology, and genetic analysis. Neurocysticercosis should be considered as a differential diagnosis in cases with atypical neurologic or psychiatric symptoms, atypical neuroimaging and travel history. Especially, fourth ventricular cysts carry the risk of obstructive hydrocephalus and brainstem compression and therefore should be extirpated completely. If complete removal of the cystic structures cannot be proven in cases with surgically treated neurocysticercosis, anthelminthic therapy and thorough follow-up examinations should be conducted.

Endoscopic transaqueductal removal of fourth ventricular neurocysticercosis: report of three cases.

In this study, we try to present our experience of transaqueductal removal of the fourth ventricular neurocysticercosis (FVNCC) with a flexible neuroendoscope. Three cases of the fourth ventricular cysticercosis were transaqueductally removed with FUJINON EB-270P flexible neuroendoscope through a frontal precoronal burr hole. The diagnosis was established on imaging and confirmed on histology in all of the cases. Complete excision of cysts in the fourth ventricle was performed in all cases with no significant intraoperative or postoperative complications. The shunt and the string-of-beads multiple cysts in the basal cistern were removed simultaneously through the orificium fistulae of the third ventricle floor with the flexible neuroendoscope. Satisfactory postoperative CSF flow around foramen magnum was detected by cine phase-contrast magnetic resonance imaging. All of the patients were asymptomatic, with an average follow-up of 6 months. The whole ventricular system can be explored easily with electrical flexible neuroendoscope. Endoscopic transaqueductal removal of the fourth ventricular cysticercosis with a flexible neuroendoscope should be recommended as the optimal choice of the disease due to its minimal invasion, fewer complications, shorter length of stay and cheaper treatment costs.

Human cerebral cysticercosis: immunolocalization of a sodium-dependent glucose cotransporter (SGLT) in larval and adult tapeworms.

Light microscopic immunocytochemistry was used to examine human brain cysticerci resected from the fourth ventricles of patients who had not been treated with anthelminthic drugs. Tissues were examined from 3 different patients undergoing surgery for treatment of hydrocephalus. A rabbit polyclonal antiserum to the peptide corresponding to amino acids 564-575 unique to the rabbit sodium-dependent, SGLT1 glucose cotransporter labeled with immunoperoxidase, localized immunoreactive SGLT epitopes. This antibody localizes SGLT1 in the apical brush borders of human enterocytes, but is negative in cytoplasm, as well as lateral and basal enterocyte membranes. Taenia solium neurocysticerci were SGLT positive; transporter protein was highly expressed on the surface microvilli of the external cyst wall. The well-developed network of small and larger osmoregulatory ducts within racemose larval cystcerci displayed high expression of SGLT cotransporter, consistent with a resorptive function for this system of tubules. Because water is cotransported with glucose molecules by the SGLT protein, its high expression in neurocysticerci may contribute to the expansive growth of these larvae in subarachnoid and intraventricular sites. The SGLT epitopes were also immunolocalized in gravid proglottids of Taenia saginata, indicating that cotransporter expression persisted in intestinal-dwelling, adult tapeworms. Cotransporter antibody was abundantly localized at the proglottid tegumentary surface and in the lateral osmoregulatory ducts, analogous to the SGLT localization in cysticerci. Furthermore, high expression of this cotransporter was seen in the branches of the uterus, suggesting that SGLT-mediated absorption of glucose and water has an important functional role within the reproductive system of adult tapeworms.

Isolated fourth ventricular cysticercus cyst: MR imaging in 4 cases with short literature review.

We describe the magnetic resonance imaging (MRI) signal characteristics of isolated (solitary lesion) intra fourth ventricular cysticercus cyst in 4 patients who clinically presented with obstructive hydrocephalus. All patients had routine MRI sequences (T1, T2, & proton density-weighted imaging), Fluid Attenuation Inversion Recovery (FLAIR), and post-gadolinium imaging followed by cerebrospinal fluid (CSF) flow study. It revealed a CSF signal intensity (on all pulse sequences), intra fourth ventricular cyst with a nidus (scolex), and wall enhancement. On T1-weighted and FLAIR images, the cyst wall and nidus (scolex) were seen in 3 cases, which were not seen in other routine sequences. The CSF flow study showed the intraluminal nature of the cyst. The MRI features suspected a cysticercus cyst, and per-operative findings and histopathological examination confirmed the diagnosis. The review of literature of the intra fourth ventricular cyst is briefly discussed.

Endoscopic approach to fourth ventricle cysticercosis.

Neurocysticercosis is the most frequently observed parasitosis of the central nervous system worldwide. The fourth ventricle is the most frequent site of intraventricular infestation, a location that carries a higher risk for CSF blockage and intracranial hypertension due to CSF blockage. A great number of patients become shunt dependent which carries a poorer prognosis. We report on a case of a patient with symptomatic obstructive hydrocephalus due to cysticercus in the fourth ventricle where an endoscopic approach via a frontal burr hole was performed. Although there is no consensus in the literature for the optimal treatment of this disease, this method seemed adequate for treatment of fourth ventricle cysticercosis in patients with hydrocephalus, aqueductal and foramen of Monro dilatations.

Fourth ventricle computed tomography indexes: standardisation and characteristics in neurocysticercosis.

OBJECTIVES: to propose standardisation of fourth ventricle dimensions and to study its characteristics in neurocysticercosis. METHOD: a control group (CG) constituted by 114 individuals with normal CT, and 80 patients with neurocysticercosis composed the group with neurocysticercosis (GN). Measures of the inner cranial diameter (Cr), fronto-polar distance between both lateral ventricles (FP), antero-posterior (AP) and latero-lateral (LL) fourth ventricle width based the standardisation of six indexes. RESULTS: AP/Cr, AP/LL and AP/FP were the more discriminative indexes, presenting in CG the mean values of 0.063, 0.267 and 0.582, respectively. The indexes in GN had values statistically higher than in CG. From GN, 51 patients had increased indexes values above 2 standard deviation of the CG mean. AP/Ll was >/= 1 in 95% of patients with ventricular shunting and in 88% with depression. It also occurred in 73% patients with satisfactory follow-up and in everybody who died. CONCLUSION: AP/Cr, AP/LL and AP/FP may represent fourth ventricle dimensions.

Transventricular, transaqueductal scope-in-scope endoscopic excision of fourth ventricular neurocysticercosis: a series of 13 cases and a review.

OBJECT: Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system worldwide. In patients presenting with acute hydrocephalus due to intraventricular NCC, surgery is the only option. Still, there is no consensus regarding the optimal surgical strategy, although neuroendoscopic excision is a promising method. However, the literature regarding the use of this modality in fourth ventricular NCC is scarce. The authors describe a series of patients with fourth ventricular NCC treated endoscopically. METHODS: The clinical records of 13 patients with fourth ventricular NCC who had presented with hydrocephalus were retrospectively analyzed. A fourth ventricular cyst was completely excised in all patients by using a transventricular, transaqueductal "scope-in-scope" endoscopic technique. Twelve endoscopic third ventriculostomies and 1 septostomy had been performed. RESULTS: Shunt placement was avoided in all patients. There were minimal peri- and postoperative complications. The mean duration of follow-up was 22.3 months (range 3-41 months). All patients had an improved clinical outcome. Follow-up neuroimaging revealed no residual lesion and a decreased ventricle size in all patients. CONCLUSIONS: The present series of patients with fourth ventricular NCC is the largest in the existing English-language medical literature. Endoscopic fourth ventricular cysticercal cyst excision along with internal cerebrospinal fluid diversion via endoscopic third ventriculostomy is an effective alternative to open microneurosurgical procedures and avoids shunt placement and its related complications.

Endoscopic transaqueductal removal of fourth ventricular neurocysticercosis with an angiographic catheter.

OBJECTIVE: Fourth ventricular neurocysticercosis (FVNCC) usually presents with obstructive hydrocephalus. Available treatment options are medical, external cerebrospinal fluid diversion, microsurgical, or endoscopic removal alone or in combination. We present our experience of transaqueductal removal of FVNCC by angiographic catheter with endoscopic third ventriculostomy with a rigid endoscope. METHODS: Ten patients (five male and five female patients; age range, 12-45 yr; mean, 23.2 years) with FVNCC with obstructive hydrocephalus underwent endoscopic removal along with endoscopic third ventriculostomy in a single sitting, through a frontal precoronal burr hole. Diagnosis was established on imaging and confirmed on histology in all of the cases. The Gaab Universal Endoscope System along with 4-mm, 30-degree rigid telescopes was used to enter the third ventricle, and a cut length of angiographic catheter was negotiated through the aqueduct for removal of FVNCC. RESULTS: Removal of the cyst was performed in all cases. A 30-degree rigid telescope provided excellent image quality, with the ability to address intra-FVNCC through the dilated aqueduct with a curved-tip catheter. None of these patients required any further surgery. There were no significant operative or postoperative complications in any of the cases. All of the patients were asymptomatic, with an average follow-up of 18 months. CONCLUSION: Transaqueductal removal of an intra-fourth ventricular cyst along with endoscopic third ventriculostomy with a rigid endoscope and catheter is an effective treatment and obviates the need for posterior cranial fossa exploration.

[Bruns' syndrome: description of a case of neurocysticercosis with pathological study]. / Síndrome de Bruns: descripción de un caso de neurocisticercosis con estudio anatomopatológico.

Bruns' syndrome is characterized by sudden and strong headache, accompanied by vomiting, acuphenos and vertigo, triggered by abrupt movement of the head and can produce deep coma and death. This can be due to neurocysticercosis by cyst in the fourth ventricle, which contains the larval stage of Taenia solium. In the last years, new cases of this parasitosis are being seen in Spain because of the immigration from endemic areas, but the clinical forms of this infestation are not varied. We present a 44 year old man Ecuadorian who has clinical symptoms consistent with Bruns' syndrome secondary to cyst in the fourth ventricle that progressed badly despite undergoing surgery with ventriculoperitoneal shunt and treatment with albendazol. Finally, he was operated with the excision of the lesion by means of suboccipital craniectomy. We conclude that this syndrome must rule out a cystic or non-cystic, intraventricular lesion and that the appropriate manipulation of the cysticerotic ventricular cysts carries a more favourable prognosis.

Endoscopic third ventriculostomy for patients with hydrocephalus and fourth ventricular cysticercosis: a review of five cases.

The authors evaluate the feasibility of performing endoscopic third ventriculostomy (ETV) in a series of five patients with ventricular outlet obstruction and a prior history of fourth ventricular cysticercosis. All patients underwent fourth ventricular cyst excision and presented at various times afterwards with hydrocephalus. They were all successfully managed with ETV, and no patient has required subsequent surgery during a mean follow-up period of 21 months (range 12-36 months).

Isolated fourth ventricular cysticercus cyst: MR imaging in 4 cases with short literature review.

We describe the magnetic resonance imaging (MRI) signal characteristics of isolated (solitary lesion) intra fourth ventricular cysticercus cyst in 4 patients who clinically presented with obstructive hydrocephalus. All patients had routine MRI sequences (T1, T2, & proton density-weighted imaging), Fluid Attenuation Inversion Recovery (FLAIR), and post-gadolinium imaging followed by cerebrospinal fluid (CSF) flow study. It revealed a CSF signal intensity (on all pulse sequences), intra fourth ventricular cyst with a nidus (scolex), and wall enhancement. On T1-weighted and FLAIR images, the cyst wall and nidus (scolex) were seen in 3 cases, which were not seen in other routine sequences. The CSF flow study showed the intraluminal nature of the cyst. The MRI features suspected a cysticercus cyst, and per-operative findings and histopathological examination confirmed the diagnosis. The review of literature of the intra fourth ventricular cyst is briefly discussed.