Neuro-endoscopic management of intraventricular neurocysticercosis (NCC)

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.

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.

Indian Neurosurgeons at the Forefront: A Comprehensive Exploration of their Pioneering Contributions to Neuroendoscopy

This article delves into the profound impact of Indian neurosurgeons on the expansive canvas of neuroendoscopy. By scrutinizing their trailblazing research, innovations, new surgical techniques, and relentless dedication to education and training, we aim to unravel the intricacies of their influence on a global scale. The review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, conducts a comprehensive analysis of the literature related to neuroendoscopy contributed by Indian neurosurgeons. The exploration covers a spectrum of achievements, ranging from pioneering research and innovations to complication avoidance, neuroendoscopic training, and global recognition. Despite challenges, Indian neurosurgeons continue to lead the way in shaping the future of neuroendoscopy, ensuring better patient outcomes and improved quality of life. Many Indian neurosurgeons have contributed significantly to the development of neuroendoscopy in India. Prof. YR Yadav's contributions stand significant in the form of research articles and publications on almost all subjects on neuroendoscopy, the textbook on neuroendoscopy, popularizing neuroendoscopy by starting the first university-certified neuroendoscopy fellowship training program in India, describing many innovative techniques/first report of endoscopic techniques and conducting regular endoscopic workshops in his institutions and other major cities of India.

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.

Neurocysticercosis presenting as a locked-in lateral ventricle: A case report and evidence-based review

Human neurocysticercosis is one of the most prevalent parasitic infestations of the central nervous system. It is considered the most frequent underlying etiology of acquired epilepsy in endemic areas in Central and South America, East Europe, Africa, and Asia, with over 50 million people affected globally. Ventricular involvement is a severe form of neurocysticercosis commonly manifests as arachnoiditis, raised intracranial pressure, or hydrocephalus, secondary to CSF flow obstruction of the ventricular system by cysts of Taenia solium, hence requiring prompt, aggressive intervention to alleviate the increased intracranial pressure to prevent imminent lethal complications. Ventricular neurocysticercosis can involve any brain ventricle but with a paramount preference for the fourth ventricle, causing non-communicating hydrocephalus and symmetric ventriculomegaly. However, in this clinical report, we present an uncommon case of trapped (locked-in) lateral ventricle caused by an isolated cysticercus trapped at the ipsilateral foramen of Monro, which is an atypical location for neurocysticercosis, adding more challenges to diagnosis and during the process of surgical extraction. We additionally provide a comprehensive, evidence-based review of the clinical course and management options relevant to the entity of ventricular neurocysticercosis, besides recent relevant clinical updates.

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.

Transventricular endoscopic approach to the anterior interhemispheric fissure for neurocysticercosis: illustrative cases

BACKGROUND

Neurocysticercosis (NCC) is a global public health problem. It is a complex disease to manage and a cause of great morbidity and mortality in affected patients. Conventional surgical approaches have been used for many years, but currently, minimally invasive approaches are being used with good results. The authors present a case of NCC in the anterior interhemispheric fissure that was treated with a transventricular endoscopic approach.

OBSERVATIONS

A 32-year-old male patient was admitted for persistent moderate headache and dizziness. Gadolinium-enhanced magnetic resonance imaging (MRI) showed multiple parenchymal, ventricular, and subarachnoid cystic lesions, especially in the anterior interhemispheric space. A transventricular endoscopic approach was selected and applied. There were no complications during surgery. Pathological analysis confirmed the diagnosis of NCC. Control MRI demonstrated the absence of cysts in the anterior interhemispheric space.

LESSONS

Minimally invasive approaches are an excellent alternative for patients with NCC, especially if a patient requires more than one surgery.

Endoscope-assisted far lateral craniotomy for resection of posterior fossa neurocysticercosis: illustrative case

BACKGROUND

Neurocysticercosis is a parasitic infection that commonly affects the ventricles, subarachnoid spaces, and spinal cord of the central nervous system. The authors report an unusual manifestation of purely posterior fossa neurocysticercosis treated with endoscope-assisted open craniotomy for resection.

OBSERVATIONS

A 67-year-old male presented with 2 months of progressive dizziness, gait ataxia, headaches, decreased hearing, and memory impairment. Imaging revealed an extra-axial cystic lesion occupying the foramen magnum and left cerebellopontine angle with significant mass effect and evidence of early hydrocephalus. Gross-total resection was accomplished via a left far lateral craniotomy with open endoscopic assistance, and pathological findings were consistent with neurocysticercosis. Postoperatively, he was noted to have a sixth nerve palsy, and adjuvant therapy included albendazole. By 9 months postoperatively, he exhibited complete resolution of an immediate postoperative sixth nerve palsy in addition to all preoperative symptoms. His hydrocephalus resolved and did not require permanent cerebrospinal fluid (CSF) diversion.

LESSONS

When combined with traditional skull base approaches, open endoscopic techniques allow for enhanced visualization and resection of complex lesions otherwise inaccessible under the microscope alone. Recognition and obliteration of central nervous system neurocysticercosis can facilitate excellent neurological recovery without the need for CSF diversion.

CystiHuman: A model of human neurocysticercosis

INTRODUCTION

The Taenia solium tapeworm is responsible for cysticercosis, a neglected tropical disease presenting as larvae in the body of a host following taenia egg ingestion. Neurocysticercosis (NCC), the name of the disease when it affects the human central nervous system, is a major cause of epilepsy in developing countries, and can also cause intracranial hypertension, hydrocephalus and death. Simulation models can help identify the most cost-effective interventions before their implementation. Modelling NCC should enable the comparison of a broad range of interventions, from treatment of human taeniasis (presence of an adult taenia worm in the human intestine) to NCC mitigation. It also allows a focus on the actual impact of the disease, rather than using proxies as is the case for other models.

METHODS

This agent-based model is the first model that simulates human NCC and associated pathologies. It uses the output of another model, CystiAgent, which simulates the evolution of pig cysticercosis and human taeniasis, adding human and cyst agents, including a model of cyst location and stage, human symptoms, and treatment. CystiHuman also accounts for delays in the appearance of NCC-related symptoms. It comprises three modules detailing cyst development, seizure probability and timing, and intracranial hypertension/hydrocephalus, respectively. It has been implemented in Java MASON and calibrated in three endemic villages in Peru, then applied to another village (Rica Playa) to compare simulation results with field data in that village.

RESULTS AND DISCUSSION

Despite limitations in available field data, parameter values found through calibration are plausible and simulated outcomes in Rica Playa are close to actual values for NCC prevalence and the way it increases with age and cases with single lesions. Initial simulations further suggest that short-term interventions followed by a rapid increase in taeniasis prevalence back to original levels may have limited impacts on NCC prevalence.

Added value of 3D-DRIVE and SWI Magnetic Resonance Imaging Sequences in Intraventricular Neurocysticercosis (IVNCC): An Institutional Experience from Northeast India

Background:

Prompt diagnosis and early treatment institution are important in intraventricular neurocysticercosis (IVNCC) as compared to the parenchymal or racemose form because it is associated with a poorer patient prognosis. Intraventricular neurocysticercosis is often missed on CT scan or conventional cranial magnetic resonance imaging because of similar density or signal intensity of cysticercus lesion with cerebrospinal fluid.Thestudy aims to evaluate the added value of 3D-DRIVE and SWI MRI sequences in isolated intraventricular cysticercosis with acute neurological presentation.

Methods and Materials:

This retrospective study was carried out on diagnosed 10 patients with isolated intraventricular neurocysticercosis (IVNCC) presented to a tertiary care hospital with an acute onset of symptoms or acute neurological deficit between June 2019 to May 2021. Relevant neurological examination, CSF analysis, a serological test of neurocysticercosis and MRI scan of the brain were performed.

Result:

Tenpatients of isolated intraventricular neurocysticercosis (3 males and 7 females) having 3 pediatric and 7 adults were included in this study sample.The common neurological complications of the isolated intraventricular neurocysticercosis in this study are observed as obstructive hydrocephalus in 8(80%) patients and ependymitis in 7(70%) patients. IVNCC with distinctly visualized scolex (visibility score 2) identified in 2(20%) patients in T2WI, 8 (80%) patients in 3D-DRIVE and 3(30%) patients in SWI sequences. The cyst wall of IVNCC was distinctly visualized (visibility score 2) in 1(10%) patient in T2WI, 8(80%) patients in 3D-DRIVE and 6(60%) patients in SWI sequence.

Conclusion:

Heavily T2-weighted steady-state and SWI sequences should be added to routine MRI sequences that helps to identify IVNCC and should be used in patients with unexplained hydrocephalus, especially in endemic regions of Neurocysticercosis.

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.

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.

Application of neuroendoscopic surgical techniques in the assessment and treatment of cerebral ventricular infection

Cerebral ventricular infection (CVI) is one of the most dangerous complications in neurosurgery because of its high mortality and disability rates. Few studies have examined the application of neuroendoscopic surgical techniques (NESTs) to assess and treat CVI. This multicenter, retrospective study was conducted using clinical data of 32 patients with CVI who were assessed and treated by NESTs in China. The patients included 20 men and 12 women with a mean age of 42.97 years. NESTs were used to obliterate intraventricular debris and pus, fenestrate or incise the intraventricular compartment and reconstruct cerebrospinal fluid circulation, and remove artificial material. Intraventricular irrigation with antibiotic saline was applied after neuroendoscopic surgery (NES). Secondary hydrocephalus was treated by endoscopic third ventriculostomy or a ventriculoperitoneal shunt. Neuroendoscopic findings of CVI were used to classify patients into Grade I (n = 3), Grade II (n = 13), Grade III (n = 10), and Grade IV (n = 6) CVI. The three patients with grade I CVI underwent one NES, the 23 patients with grade II/III CVI underwent two NESs, and patients with grade IV CVI underwent two (n = 3) or three (n = 3) NESs. The imaging features and grades of neuroendoscopy results were positively related to the number of neurosurgical endoscopic procedures. Two patients died of multiple organ failure and the other 30 patients fully recovered. Among the 26 patients with secondary hydrocephalus, 18 received ventriculoperitoneal shunt and 8 underwent endoscopic third ventriculostomy. There were no recurrences of CVI during the 6- to 76-month follow-up after NES. Application of NESTs is an innovative method to assess and treat CVI, and its neuroendoscopic classification provides an objective, comprehensive assessment of CVI. The study trial was approved by the Institutional Review Board of Beijing Shijitan Hospital, Capital Medical University, China.

Neuronavigator-guided ventriculoscopic approach for symptomatic xanthogranuloma of the choroid plexus in the lateral ventricle

Xanthogranuloma of choroid plexus is an extremely rare, benign, and mostly asymptomatic intracranial lesion. We report a case of symptomatic lateral ventricular xanthogranuloma resected via a neuronavigator-guided ventriculoscopic approach. Then we review recent English medical literature and notice that craniotomies have been the most popular treatment. But our choice of a ventriculoscopic approach possesses unique advantages such as minimized neural tissue damage, shortened operative time, less blood loss, and safer access to central structures over conventional open surgeries. Informed consent has been obtained from the patient and his immediate family regarding this case report.

Endoscopic Management of Fourth Ventricle Neurocysticercosis: Description of the New Technique in a Case Series of 5 Cases and Review of the Literature

BACKGROUND

Around 7%-33% of cases of neurocysticercosis (NCC) have intraventricular involvement, and the fourth ventricle is the most frequent site. Medical management and various surgical approaches have been described for treating this disease. The objective of this study was to describe technical modification for endoscopic fourth ventricular NCC removal in a series of 5 cases.

METHODS

In this study (January 1, 2016, to December 31, 2017), all cases of fourth ventricular NCC which were treated with a special technique (endoscopic transcortical transforaminal transaqueductal approach) using a rigid endoscope system and 6-French infant feeding tube (IFT) were included in the study. The IFT was passed through the main channel, the cyst was engaged at the tip by applying gentle suction with a 20 cm³ syringe, and the cyst was removed along with the whole endoscopic assembly. Patient's clinical, radiologic, and follow-up data were retrieved from the department database records.

RESULTS

Five patients (3 men, 2 women; mean age, 20 years; range, 11-27 years) were enrolled. All patients had features of raised intracranial pressure. Two patients also had drop attacks, and one presented with altered sensorium and one had upgaze palsy. Duration of symptoms ranged from 3 months to 3 years. All patients had isolated fourth ventricular NCC with obstructive hydrocephalus. Complete removal of the neurocysticercal cyst could be performed in all patients without any injury to the periaqueductal region or fornix. There was no intraoperative rupture of the neurocysticercal cyst. On follow-up (range, 12-28 months; mean, 19.4 months), all patients had relief of symptoms and imaging showed no cyst and hydrocephalus.

CONCLUSIONS

We conclude that our endoscopic approach is safe, simple, cost-effective, and allows minimally invasive removal of the fourth ventricle cyst and treatment of hydrocephalus without any morbidity.

Infections in the immunocompromised child

Prevention and management of opportunistic infections in children is particularly relevant in an era demonstrating an increased prevalence of immunocompromising conditions. The presence of an unusual organism which results in serious infection in a child should therefore always raise the consideration of immune compromise. The more common opportunistic infections have become easier to recognize in recent times due to improved awareness and more refined diagnostic testing. Targeted treatment is usually followed by long-term prophylactic medication. The impact of these conditions on patient outcome is of clear significance and certainly warrants further discussion.

Endoscopic Treatment of Hydrocephalus with Minimal Resources: Resource Utilization and Indigenous Innovation in Developing Countries like India

CONTEXT

Neuroendoscopic surgeries need specialized equipments, unavailable in neurosurgical departments of majority of public healthcare institutions of India. Aims: Neuroendoscopic treatment of hydrocephalus in the setting of minimal resources using utilization of available resources, inter-departmental co-ordination and indigenous innovations.

METHODS

Study was carried out at a public sector institute of India with scarce resources. Senior author (DKJ) used indigenously designed stainless steel working sheath along with equipments of 'awake endoscopic intubation system' of department of neuroanesthesia and 18 cm, 4 mm, 0° rigid telescope for neuroendoscopic surgeries for various intraventricular pathologies.

RESULTS

Thirty-four neuroendoscopic surgeries in 32 patients were done over last 3 years. There were 18 males and 14 females with average age of 23 years. It included hydrocephalus due to tubercular meningitis (n = 19), neurocysticercosis (NCC) (n = 4), intra-ventricular (n = 2) and para-ventricular (n = 2) space occupying lesions, aqueduct stenosis with (n = 2) or without (n = 1) shunt malfunction and one case each of pyogenic meningitis and right cerebellar infarction. Endoscopic third ventriculostomy (ETV) (n = 28), septostomy (n = 6), removals of cystic lesions (n = 3) and biopsies of intraventricular lesions (n = 2) were done in a total of 34 neuroendoscopic surgeries. Overall there were four failures of ETVs, which were managed by ventriculo-peritoneal shunts. Two mortalities in the study group were unrelated to the surgical procedures.

CONCLUSION

Indigenous innovations and interdisciplinary co-ordination are the way ahead to tackle resource scarcity in public sector healthcare institutions of India in the scenario of plenty of neuroendoscopic trainings opportunities for young neurosurgeons and paucity of equipments required.

Solitary Cysticercal Cyst Inside the Blake's Pouch Remnant of Mega Cisterna Magna with Associated Aqueductal Stenosis: Clinical and Management Implications

BACKGROUND

Intraventricular and subarachnoid forms represent the relatively complex, albeit uncommon, manifestations of central nervous system involvement by cysticercal cysts. Cysticercal encystation inside the Blake's pouch remnant of mega cisterna magna (MCM) remains an extremely rare clinical scenario that, to the best of our knowledge, has not been reported previously.

CASE PRESENTATION

A 12-year-old boy presented with acute worsening and subsequent spontaneous resolution of his compensated hydrocephalus. Neuroimaging revealed features consistent with a MCM with septum inside, indicating remnants of the embryologic fourth ventricular diverticulum, the Blake's pouch. It also revealed a free-floating intact cysticercal cyst inside the MCM limited by the septum with aqueductal stenosis. The spontaneous clinicoradiologic resolution of hydrocephalus raised the possibility of ball valve obstruction of the cerebrospinal fluid outflow, i.e., Bruns syndrome. We successfully treated this patient with endoscopic extraction of the viable cysticercal cyst through a suboccipital burrhole.

CONCLUSIONS

The clinical scenario presented here has not been described previously. Endoscopic cyst removal in such a situation is an effective and low-risk procedure that obviates the further need for antihelminthic medications.

[Racemose neurocysticercosis: Neuroimaging guides the diagnosis]

Neurocysticercosis is the leading cause of parasitosis of the central nervous system and acquired epilepsy in developing countries. The clinical manifestations of neurocysticercosis, especially its racemose variant, are pleomorphic and unspecific, characteristics that hinder the diagnosis and make it a challenge for the clinician.The objective of this report was to describe two cases of racemose neurocysticercosis in which neuroimaging led to the definitive diagnosis. The first case involved a patient with persistent headache and focal neurological signs. She required multiple paraclinical tests that led to the definitive diagnosis of racemose neurocysticercosis with secondary cerebral vasculitis. Despite medical and surgical treatment the patient died after multiple complications.The second case involved a patient with a history of neurocysticercosis, who consulted for chronic intractable vomiting. She required multiple paraclinical tests that led to the diagnosis of vomiting of central origin secondary to racemose neurocysticercosis and entrapment of the fourth ventricle. After medical and surgical treatment the patient showed slight improvement. In these two cases it was evident how proper interpretation of neuroimages is essential for the diagnosis of racemose neurocysticercosis.

Intraventricular migration of an isolated fourth ventricular cysticercus following cerebrospinal fluid shunting

BACKGROUND

Isolated intraventricular neurocysticercosis (NCC) is less frequently seen and can be missed on plain magnetic resonance imaging (MRI). Three-dimensional constructive interference in steady state (CISS) sequence is an extremely helpful sequence in identifying the lesion but is rarely used routinely.

CASE DESCRIPTION

Here, we report a case of young male adult who presented with diminution of vision and headache. MRI of the brain revealed hydrocephalus, and on using CISS sequence only, the lesion could be identified in the fourth ventricle. He was treated with medical management, and ventriculoperitoneal shunting of cerebrospinal fluid was done to relieve the hydrocephalus. It resulted in immediate relief with aggravation of headache few days later. Repeat MRI revealed intraventricular migration into the left foramen of monro leading to left lateral ventricle dilatation necessitating endoscopic removal of the lesion.

CONCLUSION

CISS sequence is definitely the sequence of choice in identifying intraventricular NCC. Ventriculoperitoneal shunting can result in the intraventricular migration of the cyst due to sudden decompression necessitating repeat surgery. Endoscopic removal of NCC has a high success rate with limited complications.

Intraventricular neurocysticercosis: Presentation, diagnosis and management

Neurocysticercosis is thought to be the most common helminthic infection of the central nervous system and its epidemiology is changing due to increasing travel and migration. Evidence to guide management of the intraventricular form is limited. We aimed to review the clinical presentation, diagnosis and treatment of intraventricular neurocysticercosis with reference to two recent cases seen at our institution. The intraventricular variant of neurocysticercosis is less common than parenchymal disease and usually presents with acutely raised intracranial pressure and untreated it progresses rapidly with high mortality. The diagnosis is based on imaging and serological tests but more invasive testing including histopathological examination of surgically acquired tissue specimens is sometimes required. Treatment is mainly surgical, using a neuroendoscopic approach if possible. Patients should also receive antihelmintic treatment with concomitant corticosteroids to reduce the incidence of shunt failure if a ventricular shunt is inserted and to treat viable lesions elsewhere.

Endoscopic excision of intraventricular neurocysticercosis blocking foramen of Monro bilaterally

Neurocysticercosis (NCC) is a parasitic infestation of the central nervous system. NCC parasitic infestation can be misdiagnosed as hydatid cyst or intraventricular epidermoid cyst that can cause a diagnostic dilemma. A 23-year-old male patient presented with headache and vomiting for 3-4 days and giddiness for 4-5 days. Magnetic resonance imaging with contrast was suggestive of a rim-enhancing lesion at the level of the foramen of Monro. Endoscopic excision of the lesion was done, and the patient had relief of a headache and vomiting immediately after the procedure. He is being followed up regularly. Intraventricular NCC occluding both foramen of Monro is a rare entity. Complete endoscopic surgical excision followed by appropriate drug therapy should be given to achieve a cure.

Racemose neurocysticercosis

Background:

Neurocysticercosis (NCC) is an invasive parasitic infection of the central nervous system caused by the larval stage of the tapeworm Taenia solium. The clinical manifestations of NCC depend on the parasitic load and location of infection, as well as the developmental stage of the cysticerci and host immune response, with symptoms ranging from subclinical headaches to seizures, cerebrovascular events, and life-threatening hydrocephalus. Racemose NCC represents a particularly severe variant of extraparenchymal NCC characterized by the presence of multiple confluent cysts within the subarachnoid space and is associated with increased morbidity and mortality, as well as a decreased response to treatment. Albendazole is the preferred drug for the treatment of racemose NCC due to its superior cerebrospinal fluid penetration compared to praziquantel and the ability to be used concomitantly with steroids.

Case Description:

In this report, we describe a 39-year-old man recently emigrated from Mexico with racemose NCC and hydrocephalus successfully treated with prolonged albendazole treatment, high-dose dexamethasone, and ventriculoperitoneal shunt placement for the relief of obstructive hydrocephalus.

Conclusions:

Treatment of racemose NCC represents a significant clinical challenge requiring multimodal intervention to minimize infectious- and treatment-related morbidity. We review the clinical, diagnostic, and therapeutic features relevant to the management of this aggressive form of NCC.

Application of a 980-nanometer diode laser in neuroendoscopy: a case series

OBJECTIVE

Ventricular neuroendoscopy represents an important advance in the treatment of hydrocephalus. High-power (surgical) Nd:YAG laser and low-level laser therapy (using 685-nm-wavelength diode laser) have been used in conjunction with neuroendoscopy with favorable results. This study evaluated the use of surgical 980-nm-wavelength diode laser for the neuroendoscopic treatment of ventricular diseases.

METHODS

Nine patients underwent a neuroendoscopic procedure with 980-nm diode laser. Complications and follow-up were recorded.

RESULTS

Three in-hospital postoperative complications were recorded (1 intraventricular hemorrhage and 2 meningitis cases). The remaining 6 patients had symptom improvement after endoscopic surgery and were discharged from the hospital within 24-48 hours after surgery. Patients were followed for an average of 14 months: 1 patient developed meningitis and another died suddenly at home. The other patients did well and were asymptomatic until the last follow-up consultation.

CONCLUSIONS

The 980-nm diode laser is considered an important therapeutic tool for endoscopic neurological surgeries. This study showed its application in different ventricular diseases.

Extraparenchymal (Racemose) Neurocysticercosis and Its Multitude Manifestations: A Comprehensive Review

Neurocysticercosis is an infection of the central nervous system caused by the larval form of the pork tapeworm Taenia solium. In the brain it occurs in two forms: parenchymal and extraparenchymal or racemose cysts. The clinical presentation of racemose cysts is pleomorphic, and is quite different from parenchymal cysticercosis. The clinical diagnosis of racemose cysts is quite challenging, with neuroimaging being the mainstay. However, the advent of newer brain imaging modalities has made a more accurate diagnosis possible. The primary focus of this article is racemose neurocysticercosis and its multitude manifestations, and includes a discussion of the newer diagnostic modalities and treatment options.

Emergency neuroendoscopic management of third ventricular neurocysticercosis cyst presented with bruns syndrome : report of two cases and review of literature

Neurocysticercosis is the commonest parasitic disease of the human central nervous system. The incidence of intra ventricular form of neurocysticercosis (NCC) is less common accounting 10-20% that of total central nerve system cysticercosis. Intra ventricular NCC is complicated due, to its high incidence of acute hydrocephalus caused by ball valve mechanism. The only reliable tool for diagnosis of NCC is by neuroimaging with CT or MRI. MRI preferred over CT because of its high specificity and sensitivity. In emergency situations like acute hydrocephalus one can proceed with emergency endoscopic surgery. Through the endoscopic view, intra ventricular NCC (IVNCC) has distinguished morphological features like the full moon sign. This feature not only helps in identification of IVNCC, but also guides in further endoscopic treatment strategy. Authors report two cases of 3rd ventricular NCC with acute hydrocephalus managed with emergency endoscopy. Authors have discussed the clinical features, intra operative endoscopic findings and role of endoscopy in emergency surgery for NCC with acute hydrocephalus.

Third-ventricular neurocysticercosis: hydraulic maneuvers facilitating endoscopic resection

BACKGROUND

Neurocysticercosis, an infection of the central nervous system with the larval cysts of the pork tapeworm, Taenia solium, is the most common parasitic disease of the central nervous system. The disease is a major global cause of acquired epilepsy and may also manifest as intracranial hypertension due to mass effect from large cysts or to cerebrospinal fluid flow obstruction by intraventricular cysts or inflammation of the subarachnoid space. While the condition is endemic in several regions of the world and has been appreciated as a public health problem in such regions for several decades, its emergence in the USA in areas far from the Mexican border is a more recent phenomenon.

METHODS

We present a case of surgically corrected acute hydrocephalus in a recent Haitian emigrant child due to a third ventricular neurocysticercal cyst complex.

RESULTS

We describe the endoscope-assisted en bloc removal of the complex, together with hydraulic maneuvers facilitating the removal of the intact cyst.

CONCLUSIONS

Simple hydraulic maneuvers can facilitate the endoscopic en bloc removal of third ventricular neurocysticercal cysts.

Medical management of neurocysticercosis

INTRODUCTION

Neurocysticercosis (NCC) is considered to be the most common cause of acquired epilepsy worldwide. Formerly restricted to palliative measures, therapy for NCC has advanced with the advent of two drugs that are considered to be effective: praziquantel (PZQ) and albendazole (ALB).

AREAS COVERED

All available articles regarding research related to the treatment of NCC were searched. Relevant articles were then reviewed and used as sources of information for this review.

EXPERT OPINION

Anticysticercal therapy has been marked by intense controversy. Recent descriptions of spontaneous resolution of parenchymal cysticercosis with benign evolution, risks of complications and reports of no long-term benefits have reinforced the debate over the usefulness and safety of anticysticercal therapy. High interindividual variability and complex pharmacological interactions will require the close monitoring of plasma concentrations of ALB and PZQ metabolites in future trials. Given the relative scarcity of clinical trials, more comparative interventional studies - especially randomized controlled trials in long-term clinical evolution - are required to clarify the controversy over the validity of parasitic therapy in patients with NCC.

What is the utility of postoperative antihelminthic therapy after resection for intraventricular neurocysticercosis?

BACKGROUND

Neurocysticercosis (NCC) is the most common worldwide parasitic infection of the central nervous system, and ventricular cysts are particularly problematic, carrying the risk of acute obstructive hydrocephalus. Herein, we present a typical case in which complete resection was possible and explore the evidence supporting the use of postoperative oral antihelminthic therapy.

METHODS

We performed a systematic review of the medical literature. Articles were included if they provided: 1) documentation of intraventricular disease, 2) discussion of management strategy, and 3) a presentation of outcomes. Available data were analyzed based on the primary therapy for NCC.

RESULTS

Data from 264 patients were abstracted from 32 references. Of all patients undergoing surgical resection of an isolated neurocysticercal cyst, 33.5% received postoperative antihelminthic therapy, most commonly albendazole. Among patients who had undergone surgical resection of a single intraventricular lesion (as was the case with our own patient), those who received postoperative antihelminthic therapy had a significantly lower risk of developing delayed hydrocephalus (18.8%, compared to 59.1% for those who received no medical therapy) (P = 0.02). The total mortality rate in our review was 3%.

CONCLUSIONS

This review produced surprising results: 1) the generous proportion of patients who underwent medical therapy as first-line treatment for intraventricular NCC (20.8%), and 2) the significant overall mortality. The data found in this review also provided for a strong consensus for the use of postresection antihelminthic therapy, and thus we elected to treat our index case with albendazole, assuming the risk to be low and the potential benefit meaningful.

CT Ventriculography for diagnosis of occult ventricular cysticerci

Background:

Neurocysticercosis is the most common parasitic infection of the central nervous system (CNS). Intraventricular lesions are seen in 7–20% of CNS cysticercosis. Intraventricular lesions can be missed by computed tomography (CT) and magnetic resonance imaging (MRI) as they are typically isodense/isointense to the cerebrospinal fluid. We present our experience with CT ventriculography to visualize occult cysts.

Case Description:

Two patients presented with hydrocephalus and suspected neurocysticercosis were evaluated with CT and MRI with and without contrast failing to reveal intraventricular lesions. CT-ventriculography was used: 10 ml of cerebrospinal fluid was drained from the ventriculostomy catheter, and 10 ml of iohexol 240 diluted 1:1 with preservative-free saline was injected through the ventriculostomy catheter. Immediate CT of the brain was performed. The first patient had multiple cysts located throughout the body of the left lateral ventricle. The second patient had a single lesion located in the body of the lateral ventricle. The CT-ventriculography findings helped in identifying the lesions and plan the surgical intervention that was performed with the aid of an endoscope to remove the cysts.

Conclusions:

Intraventricular neurocysticercosis is a common parasitic disease which can be difficult to diagnose. We used CT-ventriculography with injection of contrast through the ventriculostomy catheter in two patients where CT and MRI failed to demonstrate the lesions. This technique is a safe and useful tool in the imaging armamentarium when intraventricular cystic lesions are suspected.

Intraventricular and subarachnoid basal cisterns neurocysticercosis: a comparative study between traditional treatment versus neuroendoscopic surgery

OBJECTIVE

The purpose of this study was to evaluate the efficacy of traditional treatment and minimal invasive flexible endoscopy surgery (MIFNES) in the treatment of intraventricular and subarachnoid basal cisterns neurocysticercosis (NCC).

METHODS

This was an observational comparative study of two independent series with a total of 140 patients with extremely severe forms of NCC from two different institutions. All 83 patients submitted for traditional treatment series received albendazole, and some of them received additionally praziquantel. Each cycle of both regimens lasted 4 weeks. The majority of these patients had at least one ventriculoperitoneal (VP) shunt. The rest 57 patients were submitted to the MIFNES treatment. The follow-up period was at least 6 months.

RESULTS

In all patients of both series cysticercal cysts disappeared, became calcified, or were removed. Symptoms of 136 patients improved. Four patients died. The average in the quality of life measured using the Karnofsky scale improved from a mean of 52.22 and 52.44 at the beginning to 85.48 and 90.37 at 6 months (p < 0.003), in the traditional treatment and MIFNES series, respectively. From traditional treatment, almost all patients remained with at least one VP shunt, and from the MIFNES series only 12 patients.

CONCLUSIONS

The authors postulate that MIFNES is a good alternative for the management of intraventricular and subarachnoid basal cisterns NCC because it allows removal of most of the parasites, rapid recovery of the patients, and removal and placement of shunt under direct vision when necessary. Traditional treatment is a second option where the MIFNES procedure is not available.

Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report

OBJECTIVE

This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricular-endoscopic route for decompression of a giant pituitary adenoma.

METHOD

A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5 x 3.5 x 2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard trans-sphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricular-endoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone.

RESULTS

Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour.

CONCLUSIONS

This novel technique of the combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone.

Endoscopic management of brainstem injury due to ventriculoperitoneal shunt placement

INTRODUCTION

We report a patient who suffered from brainstem injury following ventriculoperitoneal (VP) shunt placement in the fourth ventricle.

DISCUSSION

A 20-year-old man with complex hydrocephalus and trapped fourth ventricle underwent a suboccipital placement of a VP shunt. Postprocedure patient developed double vision. Magnetic resonance imaging showed that the catheter was penetrating the dorsal brainstem at the level of the pontomedullary junction. Patient was referred to our Neuroendoscopic Clinic. Physical exam demonstrated pure right VI cranial nerve palsy. Patient underwent flexible endoscopic exploration of the ventricular system. Some of the endoscopic findings were severe aqueductal stenosis and brainstem injury from the catheter. Aqueductoplasty, transaqueductal approach into the fourth ventricle, and endoscopic repositioning of the catheter were some of the procedures performed. Patient recovered full neurological function. The combination of endoscopic exploration and shunt is a good alternative for patients with complex hydrocephalus. A transaqueductal approach to the fourth ventricle with flexible scope is an alternative for fourth ventricle pathology.

Surgical management of adult hydrocephalus

The management of adult hydrocephalus spans a broad range of disorders and ages. Modern management strategies include endoscopic and adjustable cerebrospinal fluid shunt diversionary techniques. The assessment and management of the following clinical conditions are discussed: 1) the adult patient with congenital or childhood-onset hydrocephalus, 2) adult slit ventricle syndrome, 3) multicompartmental hydrocephalus, 4) noncommunicating hydrocephalus, 5) communicating hydrocephalus, 6) normal pressure hydrocephalus, and 7) the shunted patient with headaches. The hydrodynamics of cerebrospinal fluid shunt diversion are discussed in relation to mechanisms of under- and overdrainage conditions. A rationale for the routine implementation of adjustable valves for adult patients with hydrocephalus is provided based on objective clinical and experimental data. For the condition of normal pressure hydrocephalus, recommendations are offered regarding the evaluation, surgical treatment, and postoperative management of this disorder.

Endoscopic excision of intraventricular neurocysticercosis in children: a series of six cases and review

OBJECTS

Neurocysticercosis (NCC) affects both adults and children, but it is uncommon in childhood. The clinical presentation and management of intraventricular neurocysticercosis (IVNCC) in children has not been described adequately. We, therefore, present our series of six children with IVNCC managed by endoscopic excision.

MATERIALS AND METHODS

A retrospective analysis of six children with IVNCC was performed. The endoscopic technique practiced is described. Complete excision of the intraventricular cyst was performed in all patients. Simultaneously, five endoscopic third ventriculostomies, one septostomy, and one foramenotomy were performed. There were no perioperative and postoperative complications. Mean follow-up duration was 24.8 months. Clinical improvement was seen in all children, and none required shunting. Follow-up radiology showed no residual lesion and decreased ventricle size in all patients.

CONCLUSION

Endoscopic IVNCC cyst excision along with internal CSF diversion is a safe and effective option and avoids shunt and its related complications in these children.

THE SURGICAL MANAGEMENT OF INFECTIONS INVOLVING THE CEREBRUM

OBJECTIVE

Infection involving the cerebrum is a true neurosurgical emergency that requires rapid diagnosis and appropriate surgical and medical intervention to achieve good clinical outcome.

METHODS

Because of the potential for devastating neurological sequelae, it is imperative that neurosurgeons be involved in the diagnosis and management of these serious conditions once an infection is suspected. With the advent of computed tomography and magnetic resonance imaging, it is now possible to detect an infectious process early in its course and follow the response to therapy. Although significantly more effective than in the past, antimicrobial therapy alone is insufficient to eradicate most intracranial infections, especially in the presence of compression or displacement of the cerebrum. Surgery remains an essential part of the management of intracranial infection because of its ability to provide immediate relief from pressure on neural structures and thereby result in clinical improvement.

RESULTS

The most common infections affecting the brain, namely, cranial epidural abscess, subdural empyema, brain abscess, viral infection, tuberculosis, and neurocysticercosis, can each be associated with significant mass effect on the cerebrum that is greatly reduced through surgery. This relief, in combination with newer antimicrobial agents that have an improved ability to cross the blood brain barrier, has led to a reduction in the infection-related morbidity and mortality rates associated with intracranial infections.

CONCLUSION

Combining advanced imaging and surgical techniques in the form of intraoperative magnetic resonance image-guided neurosurgery may further enhance clinical outcomes in these once uniformly fatal diseases.

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.

Zoonotic helminth infections of humans: echinococcosis, cysticercosis and fascioliasis

PURPOSE OF REVIEW

Tissue parasites of humans are still prevalent in most regions of the world, and are also seen more frequently in developed countries due to increasing travel patterns. In particular, Echinococcus infections still account for hepatic and pulmonary pathology, cysticercosis is a major cause of seizures and epilepsy, and fascioliasis also causes significant liver pathology. This review summarizes current knowledge on clinical and epidemiologic aspects of zoonotic disease caused by tissue helminths.

RECENT FINDINGS

Tissue helminth infections remain as a public health concern. Recent research has provided new insights into clinical disease in humans and improved methods for diagnosis, treatment and control, arising mostly from the application of new techniques for immune and molecular diagnosis, availability of data from controlled trials, and development of new vaccines. Specific antiparasitic therapies are now better characterized, and new control tools are available.

SUMMARY

Recent research has provided new diagnostic technologies applicable to diagnosis, treatment and control, but effective interventions to reduce transmission are rarely applied. Despite some progress in their control, these zoonoses continue to be a major public health problem in many regions both in developing countries and in some more developed ones.