Case report on cause of adult onset seizures Neurocysticercosis

1. 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-Mosabihi2 2
KING SAUD MEDICAL COMPLEX
NeuroradiologySection:
2013, Dec. 7Published:
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

2. 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

3. 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

4. Mildly dilated ventricles with sub-ependymal oedema. Multiple small cystic lesions with
calcified 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 in
right 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;

5. 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

6. 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;

7. 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

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