Cerebral cysticercosis in Mexico

Intrathecal gadodiamide for identifying subarachnoid and ventricular neurocysticercosis

OBJECTIVE

Some neurocysticercosis cysts may remain hidden despite novel MRI sequences. This study evaluates the diagnostic value of gadodiamide (GDD)-contrasted MRI cisternography in selected cases of neurocysticercosis.

METHODS

We included patients aged 18-65 years with a probable diagnosis of subarachnoid cysticercosis in whom previous neuroimaging studies failed to demonstrate the presence of cysts. One millilitre of GDD was administered intrathecally as a contrast agent with subsequent performance of MRI.

RESULTS

Fourteen patients were included. Optimal contrast diffusion was achieved in nine patients, and partial diffusion was achieved in 4. Intracranial vesicles were identified in 10 patients, with the presence of more than 60 basal subarachnoid vesicles being revealed in all, with five cysts in the fourth ventricle in four patients and a floating cyst in the lateral ventricle in one. In one case, intrathecal GDD demonstrated spinal cysticercosis. No adverse events were reported after intrathecal GDD administration.

CONCLUSIONS

Intrathecal GDD administration is useful for the diagnosis of subarachnoid and intraventricular neurocysticercosis and can be used to improve diagnostic accuracy in selected cases.

Doença cerebrovascular e neurocisticercose

Apresentamos três casos de arterite do sistema nervoso central associada a neurocisticercose. No primeiro caso, relatamos a ocorrência de arterite bilateral das artérias cerebrais médias em um paciente de 36 anos, com quadro de hemiparesia direita e afasia. A ressonância nuclear do encéfalo evidenciou cisto racemoso parietal direito e infarto temporal esquerdo. O estudo angiográfico mostrou oclusão total da artéria cerebral média esquerda e oclusão subtotal da artéria cerebral média direita. No segundo caso demonstramos a ocorrência de vasculite de pequenos vasos em um paciente de 42 anos, com quadro de cefaléia, crises convulsivas, afasia e déficit motor. A tomografia de crânio revelou calcificações intraparenquimatosas e área isquêmica temporal esquerda. O estudo angiográfico cerebral revelou-se normal. O terceiro caso trata de uma paciente de 53 anos de idade com história pregressa de seis episódios de acidente vascular cerebral e quadro atual de distúrbio do comportamento e convulsões. A tomografia e ressonância nuclear magnética de crânio revelaram múltiplos infartos lacunares e cistos cisternais. A angiografia cerebral mostrou arterite de vasos intracranianos tanto do sistema carotídeo como vértebro-basilar. Nos três casos o estudo quimiocitológico do líquor mostrou pleocitose linfomonocitária e reação imunológica (ELISA) para cisticercose positiva.

Cysticercosis and epilepsy: a critical review

Neurocysticercosis (NC) remains a major public health problem in developing and some developed countries. Currently, the best procedures for diagnosing NC are neuroimaging studies. Immunoserologic assays, such as enzyme-linked immunoelectrotransfer blot assay (EITB) or enzyme-linked immunosorbent assay (ELISA), detect antibodies against Taenia solium, or cysticercus. Consequently, they are useful in identifying a population at risk of contact with the parasite but do not necessarily indicate a systemic active infection. Most seropositive individuals are asymptomatic. No data from prospective studies concern the proportion of these individuals that will develop seizures or other neurologic symptoms. There is a discrepancy between the results of serologic assays and neuroimaging studies: >50% of those individuals with NC diagnosed by computed tomography (CT) scan test EITB negative. Pathophysiologic classification of NC into active, transitional, and inactive forms permits a good correlation between clinical manifestations and neuroimaging procedures and facilitates medical and surgical management and research. The most frequent clinical manifestations of NC are seizures. We assume that NC is the main cause of symptomatic epilepsy in developing countries; however, no case-control or cohort studies demonstrate this association. Most patients with NC with seizures have a good prognosis; nevertheless, further studies analyzing factors related to recurrence of seizures and possibilities of discontinuation of antiepileptic medications (AEDs) are needed. Regarding treatment of NC with antihelminthic drugs, no controlled clinical trials exist that establish specific indications, definitive doses, and duration of treatment. The most effective approach to taeniasis/cysticercosis infection is prevention. This should be a primary public health focus for developing countries. We critically review the available information regarding the epidemiology and diagnosis of human cysticercosis, the physiopathology and imaging correlation of the parasite in the central nervous system (CNS) of the host, the relation between seizures or epilepsy and NC, and the issues surrounding the treatment and prognosis of NC, including the use of antihelminthic therapy.

Frequency of cerebral arteritis in subarachnoid cysticercosis: an angiographic study

BACKGROUND AND PURPOSE

Subarachnoid cysticercosis is a well-recognized cause of cerebral infarction. However, few patients with this infection develop cerebral infarction, and the reason for this is not known. The aim of this study was to determine the frequency of cerebral arteritis in these patients.

METHODS

Using cerebral arteriography, we studied 28 patients with subarachnoid cysticercosis admitted to our hospital from July 1993 to February 1996. All patients underwent MRI to detect the presence of basal arachnoiditis. We analyzed demographic data, time to cysticercosis since the first symptom onset, mode of onset, stroke syndromes, neuroimaging features of cysticercosis and cerebral infarction, and arteriographic findings for each patient.

RESULTS

Of the 28 patients (mean age, 37 years), 15 patients had angiographic evidence of cerebral arteritis (53%); 12 of the 15 had a stroke syndrome (P=.02). Eight of the 15 patients (53%) with cerebral arteritis had evidence of cerebral infarction on MRI, whereas only one patient without cerebral arteritis had cerebral infarction (P=.05). The most commonly involved vessels were the middle cerebral artery and the posterior cerebral artery.

CONCLUSIONS

The frequency of cerebral arteritis in subarachnoid cysticercosis is higher than previously reported, and middle-size vessel involvement is a common finding, even in those patients without clinical evidence of cerebral ischemia.

Proposal of diagnostic criteria for human cysticercosis and neurocysticercosis

Taenia solium cysticercosis is a major public health problem in several areas of the world. While the disease has a recognized etiologic agent, its definitive histological diagnosis is not possible in most cases because this parasite tends to lodge in cerebral tissues where routine biopsy is not feasible. Therefore, the diagnosis of human cysticercosis (and neurocysticercosis) should rest on the proper interpretation of the patients' symptoms together with data provided by radiological studies and immunologic tests for the detection of anticysticercal antibodies. Unfortunately, the pleomorphism of this parasitic disease creates confusion when non-specific clinical, radiological, or immunologic criteria alone are used to detect cases among populations or to diagnose hospitalized patients with neurological manifestations. We propose a chart of diagnostic criteria for human cysticercosis that objectively permit clinicians and health care workers to evaluate clinical, radiological, immunologic, and epidemiologic data of patients. The chart uses four degrees of criteria: absolute, major, minor, and epidemiologic, that were selected on the basis of their individual diagnostic strength. Interpretation of such criteria will result in three categories of diagnostic certainty: definitive, probable and possible, according to the likelihood that cysticercosis is present in a given person.

Childhood neurocysticercosis in south India

A total of 21 cases of childhood neurocysticercosis seen over five years (1985-89) at JIPMER hospital Pondicherry, are reported. Nine of these patients were males and twelve females. Their age ranged between 5 to 15 years. The presenting features were convulsive seizures (14), features of raised intracranial pressure (6) and meningoencephalitis syndrome (1). Diagnosis of neurocysticercosis was based on positive CSF serological tests (11), CT morphology (11), brain biopsy (1) and autopsy (1). Praziquantel therapy was given in 4 cases, 3 of them showed remarkable improvement in neurological status and one died of acute reaction.

[Neurocysticercosis in the State of Espiríto Santo, Brazil: evaluation of 45 cases]

We analyzed the clinical course, laboratory tests, evolution, and epidemiological features of 45 patients with the diagnosis of neurocysticercosis (NC) referred to Neurology Service of Hospital Cassiano Antonio Moraes, Universidade Federal do Espirito Santo, from January 1987 to January 1989. This study represents the first survey of that pathology in the State of Espirito Santo, and has led us to conclude that neurocysticercosis is endemic in this part of the country. The diagnosis was based on clinical features, CSF abnormalities proper to NC and cranial CT scans to search for cysts, calcifications and ventricular abnormalities. The diagnosis of NC was corroborated by the finding of at least two of these criteria. No statistical differences were found for sex and/or age distribution. Intracranial hypertension and epilepsy were among the most common clinical symptoms. The treatment was adequate to each patient, and varied from symptomatics to specifics. Praziquantel (PZQ), as well as surgery when indicated (ventricular-peritoneal shunt and/or cysts resection) were used. No statistical differences were found in the follow-up of the patients who were under PZQ alone and those who used PZQ plus steroids (associated). Surgery was of great benefit for those patients with intraventricular NC and severe intracranial hypertension. All patients were under close observation on periodical clinical visits during the time of this study, and we have demonstrated that neurocysticercosis is a strongly recurrent endemic pathology.

[Neurocysticercosis: incidence in the state of Rio de Janeiro]

One hundred patients with neurocysticercosis born and residents in Rio de Janeiro State were studied from September 1981 to December 1989. The approximate incidence rate of one case per month shows that the disease is not rare in this State of Brazil.

[Neurocysticercosis. I. Clinical and laboratory course of 151 cases]

Neurocysticercosis is a serious public health problem in our midst, which accounted for 7.3% of the hospital admissions and 2.7% of all cases of the out patient clinic attendance of the Discipline of Neurology of the School of Medicine--Ribeirão Preto, São Paulo University, from 1979 to 1986. A total of 151 patients with a minimum follow-up of 6 months were selected for the present study including clinical and laboratory evolution, a topic which is rarely considered in the literature. The onset of the disease was characterized by: epileptic seizures in 82 patients (54.3%), increased intracranial pressure (ICP) in 40 (26.5%), meningitis in 21 (13.9%), headache in the absence of increased ICP or meningitic signs in 7 (4.6%), and spinal cord syndrome in 1 (0.6%). In the group with the epileptic form, 36.6% of the patients later developed other neurological syndromes, such as cysticercotic meningitis, mental disorders and increased ICP after a 6 to 7 years interval. In the group with the hypertensive form, 55% of the patients developed other manifestations during the period of evolution, especially meningitis and epileptic seizures, after a significantly shorter interval than for the epileptic form. In the meningitic form, 19% of the patients showed a recurrence of the syndrome after a mean interval of 10.7 weeks: an additional 66.6% developed a combination with other syndromes, especially increased ICP and epileptic seizures. The death rate was 7.9%, the main cause being increased ICP (83.3%). When the abnormalities of the complementary tests were investigated in the various forms of clinical presentation in terms of their predictive value it was concluded that, in the epileptic form, the presence of cysts in CT scan and/or abnormalities in CSF indicates a greater risk of developing other neurologic syndromes. No significant differences in the patterns of abnormalities of these investigations were detected in the remaining clinical forms. Most cystic lesions detected by CT scan (90.9%) were associated with CSF abnormalities, especially pleocytosis and positive complement fixation test. Conversely, this proportion was only 26% in patients with calcifications.

Incidence and prevalence studies in epilepsy and their methodological problems: a review

Epidemiological studies in epilepsy have a number of specific problems, discussed here with reference to the published literature. Case ascertainment may pose difficulties because of deficiencies in patients reporting and in the diagnosis of seizures, and inherent methodological problems; the classification of epilepsy is often arbitrary and definitions variable; unsuspected selection bias may markedly influence incidence and prevalence rates. The major published incidence and prevalence studies are reviewed and the factors influencing these rates discussed.

A prognostic classification of cerebral cysticercosis: therapeutic implications

Cerebral cysticercosis is a parasitic infestation with a highly variable prognosis and diverse clinical manifestations. Over the period of two years 51 patients were studied prospectively with this infestation, paying particular attention to the duration and severity of the illness, clinical course, CT findings and therapeutic modalities. Patients with parenchymal cysts or calcification without hydrocephalus had a benign disorder presenting commonly with seizures. This type of infestation usually is long-standing, almost never requires surgical treatment, responds to praziquantel therapy and has a good prognosis. In contrast, patients who present with hydrocephalus, large supratentorial cysts, multiple granulomata with cerebral oedema or with vasculitis and cerebral infarction, have an aggressive, acute or subacute illness, presenting with raised intracranial pressure, gait disturbances, mental changes, seizures, cranial nerve palsies, hemisphere syndromes, chronic meningitis and stroke. This malignant form usually requires surgical therapy, does not respond to praziquantel and may produce a fatal outcome or serious sequelae.

Anticysticercous antibodies in serum and cerebrospinal fluid in patients with cerebral cysticercosis

Fifty-one cases of cerebral cysticercosis proved by surgery or CT scanning were studied prospectively with the ELISA test in order to detect anticysticercous antibodies in blood and CSF. The ELISA test was also performed for detection of antibodies in 20 control patients who had CSF withdrawn during a myelogram and in 119 serum samples of asymptomatic subjects. We found an overall sensitivity of the ELISA test in the blood of 87% with a specificity of 90%. In the CSF we found a sensitivity of 87% with a specificity of 100%. However, when we compared patients with cerebral cysticercosis of a benign type with patients with cerebral cysticercosis of a malignant type we found a serum sensitivity of 75% for the benign group as compared to 93% of the malignant group. The CSF sensitivity was 80% in the benign group and 93% in the malignant group. This difference was statistically significant.

Central nervous system cysticercosis simulating an acute cerebellar hemorrhage

We report the case of a Mexican man who suddenly developed severe occipital headache, vomiting, vertigo, and ataxia. Neurologic examination showed nystagmus and cerebellar findings. Computed tomography of the brain demonstrated a large left cerebellar cystic lesion consistent with the diagnosis of cysticercosis. The patient was treated with dexamethasone and praziquantel and required surgical removal of the lesion to prevent herniation. He recovered without neurologic sequelae. The abrupt onset of cerebellar findings is an unusual presentation of this disease. Central nervous system cysticercosis is being recognized with increasing frequency in the United States, where it is found primarily in Hispanic and Asian immigrants. The literature of central nervous system cysticercosis is reviewed and the pathogenesis, clinical presentation, and therapy are discussed.

Cerebral cysticercosis presenting as mass lesion

Four cases of cerebral cysticercosis that presented as brain tumor are reported. The diagnosis of these lesions was possible only after the operation. The clinical manifestations of these patients are discussed. The findings on computed tomography scanning as well as the possibilities for differential diagnosis are presented. All the patients were operated on and the diagnosis confirmed histologically. The difficulties encountered at the operations and the alternative methods for the treatment of these lesions are discussed.

Cysticercosis. A modern day plague

The authors describe the magnitude of the cysticercosis problem and describe the organism, the clinical features of the disease, the propensity of the organism for development in the central nervous system, pathologic considerations, clinical diagnosis, and treatment.

Cysticercosis cerebri. Report on seven cases

The authors report the clinical features, diagnosis and treatment of seven personal cases of cerebral cysticercosis. The epidemiology, anatomical location and therapeutic possibilities are studied. A brief review of the literature of 814 cases of neurocysticercosis is also reported.

Enzyme-linked immunosorbent assay for the diagnosis of cerebral cysticercosis

Central nervous system cysticercosis is common in countries where Taenia solium occurs in pigs and the level of hygiene and sanitation is low. The clinical presentation may include epileptic seizures, focal neurological deficits, hydrocephalus, or aseptic meningitis. The disease is frequently seen in California residents of Hispanic origin. It sometimes occurs in whites from homes that employ Hispanic cooks. Diagnosis is often difficult. Computerized tomography scan and brain biopsy are the most reliable diagnostic procedures, but each has its limitations. We have found that a radioimmunoassay improves our diagnostic capability, and more recently we have adapted this to an enzyme-linked immunosorbent assay that is equally sensitive and specific and, in addition, obviates the need for radioactive materials. Details of the enzyme-linked immunosorbent assay procedure and its application to the diagnosis of central nervous system cysticercosis form the basis of this report.

Ocular and orbital cysticercosis in hogs

The prevalence of cysticercosis in hog muscles was correlated with oculo-orbital prevalence, and histologic characteristics of changes in the parasite and hog were observed. The orbital contents, globe, and eyelids of 39 hogs affected with Cysticercus cellulosae were examined. Thirty-seven parasites were found: 35 within the orbit and two intraocular. Twenty parasites with adjacent host tissue were studied histologically. Inflammatory infiltrates ranging from diffuse lymphoplasmacytic to dense granulomas were seen in 16 cysticerci. The scolex was unaltered in all specimens.

Surgical considerations in treatment of intraventricular cysticercosis. An analysis of 45 cases

Infestations of the human brain with the larval stage of Taenia solium, once an infrequent diagnosis in the United States, is now a more frequently encountered clinical entity especially in population centers with high immigrant flux. During a recent 5-year period 45 cases of intraventricular cysticerosis have been evaluated and treated. Modes of involvement included isolated cyst formation, ependymitis, or combinations of both. Evidence of associated parenchymatous involvement was present in 20% of cases. Sites of infestation included the lateral ventricle (five cases), third ventricle (12 cases), Sylvian aqueduct (four cases), and fourth ventricle (24 cases). Mean post-therapy follow-up periods for this series exceed 36 months. This experience indicates that direct excision is the treatment of choice for ventricular cystic lesions, but that management, operative planning, and expectations should be influenced by considerations of: 1) the potential for acute clinical deterioration (38%); 2) the potential for cyst migration; 3) attendant ependymitis, defined by computerized tomography or verified at surgery; 4) the potential for increase in cyst volume with local mass effect; 5) selection and institution of corridors of surgical access that establish alternative routes of cerebrospinal fluid flow; and 6) the possibility of cyst excision by a stereotaxic endoscopic procedure.

The computed tomographic spectrum of cerebral cysticercosis

The main findings observed in computed tomography (CT) of the brain of 116 patients with cerebral cysticercosis are reviewed. Calcifications, cysts, nodules, hydrocephalus and inflammatory reactions are better detected by CT than through the use of any of the conventional neuroradiologic procedures, and surgical cases are more properly selected.

Radiology--including computed tomography--of parasitic diseases of the central nervous system

Neurocysticercosis is the commonest parasitic infection seen in India. Echinococcus is rare. In cysticercosis multiple diffuse cystic parenchymal lesions predominate in the East, whereas multiple diffuse basal racemose ones predominate in the West. Because of their protean and varied clinical picture, each patient in the past had at least two contrast studies and some even three such studies, before the availability of the CT scan. Angiographic evidence of arteritis and infarcts is documented in the Mexican studies and not seen in the Indian studies. Air studies reveal atrophy of brain parenchyma with demonstration of large cysts, intraventricular or basal. Small diffuse cysts are rarely demonstrated on these studies. CT has proved to be a boon in separating the various pathological groups. The diffuse parenchymal group shows an image morphology of throttled ventricles with or without high attenuating sago grain lesions. This is pathognomonic in endemic areas. The CT image of the localized parenchymal lesions is non-specific and can be mistaken for granulomas, abscesses or tumour. The intraventricular group and basal racemose forms give rise to oozing ventricles with obstructive of communicating hydrocephalus and disproportionate enlargement of the aqueduct and fourth ventricle in the acute stage. The cyst itself is not seen separate from the CSF in the ventricles. The disease runs a prolonged course of relapses and remissions leading to parenchymal atrophy and calcification of the intracranial and soft tissue cysts. The incidence and morphology of calcification varies in different parts of the world from 2.8% in India to 39% in Mexico and 71% in Los Angeles.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical aspects of neurocysticercosis: analysis of 500 cases]

This was a retrospective study, made at the Hospital das Clinicas University of São Paulo Medical School--Ribeirão Preto from 1956 to 1979 in 500 patients with neurocysticercosis. To our knowledge, this represented the largest sample analysed so far. Clinical manifestations and complemmentary tests were studied. The neurocysticercosis is a serious endemic disease in our region and represented 2.7% of all clinical evaluations by the Neurology Department and 7.5% of all hospital admissions. The most frequent clinical presentations were the epileptic (64.8%), the intracranial hypertension (35.6%), and the meningitic (29%). Radiological study of the skull showed intracranial calcifications suggestive of cysticercosis in 47.6%. The cerebrospinal fluid was abnormal in 81.3%: pleocytosis in 60.9%, increased protein in 49.1% and increased pressure in 29%. The presence of eosinophils occurred in 41.9%, and the Weinberg test was positive in 62,6% of all the cases. It was discussed the utility of the different drugs and the results of the surgical treatment in neurocysticercosis drawing the conclusion that they show no efficacy when analysed at the end of a long follow-up. Since none of the drugs seems to be really efficient, only the sanitary education will be able to control this endemic disease that grasses among us with so somber perspectives.

Clinical manifestations and sequential computed tomography scans of cerebral cysticercosis in childhood

Cerebral cysticercosis was studied in 131 children. The patients were divided into two groups, confirmed and probable cysticercosis. The clinical picture may be divided into two stages: initial stage of acute invasion and chronic encephalitic stage. Symptoms in the initial stage are headache, vomiting, fever, myalgia, abdominal pain, seizures and psychotic reactions. In the initial stage only cerebral edema can be seen in the computed tomography (CT) scan. In the chronic stage, variability of symptomatology is great, and it is in this phase that cysticerci can be seen in the CT scan. Only 66 out of the 131 patients studied had CT performed. The computed tomographic sequence of parenchymatous brain cysticercosis is described. A feature not previously reported was the presence of transient arterial hypertension due to cerebral cysticercosis found in four cases.

Childhood cerebral cysticercosis: clinical features and computed tomographic findings in 89 Mexican children

Cerebral cysticercosis was studied in 89 Mexican children. These patients were divided into two groups; those with proven diagnosis and those in whom the diagnosis was strongly suspected. The frequency of childhood cysticercosis at autopsy is significantly less than reported in adults from the same environment. Symptoms of initial cerebral invasion by the parasite include headache, fever, vomiting, and seizures. Cerebral edema is observed more frequently in children than in adults, and is the most common cause of intracranial hypertension. The cerebral edema generally is associated with an encephalitic syndrome, either a single bout or a chronic course with multiple relapses. Arterial hypertension, not previously described, was found in two probable cases. The variability of clinical symptomatology thus is great. Symptoms in childhood cerebral cysticercosis may be totally absent, moderate, or severe and ultimately fatal. Computed tomography of the brain is the most useful diagnostic aid, and determines the dynamic neuroradiologic sequence of this disease, since different images appear at each stage to permit its diagnosis. Uncalcified cysticerci may be demonstrated by contrast enhancement if associated with focal cerebral edema; images thus may disappear and reappear in the clinical course of the disease.

CNS cysticercosis--a problem of differential diagnosis

Although a well-known disease worldwide, cerebral cysticercosis in European countries is a rare event. Due to increased travel to East-Asian and Latin American countries it is possible that the occurrence of brain cysticercosis will become more frequent. These facts should remind us of the possibility of cysticercosis of the nervous system. A case of cerebral and spinal cord cysticercosis is presented, causing symptoms of progressive dementia with ventricular occlusion and hydrocephalus. Differential diagnosis causes a major problem. It is shown that myelography may demonstrate characteristic features of the disease.

A case of cysticercosis cerebri. Neurotologic implications

Cysticercosis is an unusual disease entity in the United States. A case is reviewed in which a young Mexican-American female presented to an otologist's office with a headache and vertigo. Her symptoms were a manifestation of a single larval cysticercus cyst which had become lodged in the fourth ventricle resulting in an obstructive hydrocephalus and a fatal course. The epidemiology of this disease traces the life cycle of the pork tapeworm from man, normally the definitive host, to the pig, the intermediate host. It is noteworthy that the disease cysticercosis in humans is a deviation from the parasite's normal life cycle in which man serves as the intermediate host. The literature is reviewed. The broad clinical spectrum of this disease's presentation can extend from a single headache to multiple nerve palsies and convulsions. The importance of radiographic evaluation complement fixation testing and CSF evaluation in making a diagnosis is stressed. There is no known medical treatment for this disease. Surgical procedures such as primary excision and shunts to relieve intracranial pressure have had mixed results. The prognosis depends on the location and the number of infesting larva. Special note is made of this disease's endemic status in Mexico and other Latin American countries and the role that this may play in medicine practiced in the southwest United States considering the ever-increasing immigration from this area.

Neurosurgical considerations of cysticercosis of the central nervous system

Infestation of the central system (CNS) by the larval form of Taenia solium can be etiological for one or more of several clinicopathological manifestations. Experience gained from treating 18 patients forms the basis for a classification of this disease and for observations upon therapy. Twenty-three surgical procedures in 15 of the 18 patients provide the foundation for comment on operative treatment in management. Whereas most procedures are palliative, eradication of the CNS disease may be achieved in cases of solitary intraventricular cysts. There has been no operative mortality.

Liquido cefalorraquiano na cisticercose encefalica

Foi feito um estudo do comportamento do líquido cefalorraquiano (LCR) na cisticercose encefálica, com base em 656 observações retiradas de um material constituído por 120.000 exames de pacientes neurológicos e psiquiátricos, reunidas em 35 anos de trabalho. Com base nos casos comprovados por necrópsia ou cirurgia foram descritas as alterações do LCR. O estudo consecutivo de amostras de LCR obtidas em anos sucessivos, durante o decurso da doença, mostrou a persistência das alterações em numerosos casos, mesmo depois de 4 a 18 anos de observação. A reação de fixação de complemento para cisticerco permaneceu positiva durante todos estes anos. Foram também apreciadas as modificações do LCR em casos de cisticercose sub-cutânea e do globo ocular e em casos com cisticercos calcificados no encéfalo.

A Histopathological Study On Human Cysticercosis

A study was made on 258 cases of cysticercosis, that were examined and diagnosed at the Department of Pathology, College of Medicine, Seoul National University during a period of 9 years from 1968 to 1976 inclusive. There were a total of 35,363 surgical specimens examined during the same period, thus revealing the relative frequency ratio of cysticercosis among surgical accessions to be 0.73%. The common sites of involvement of cysticercosis were skeletal muscle, subcutaneous tissue, breast, brain and eye in decreasing order of frequency. Painless palpable nodules were the most common initial presentation clinically. Histopathological staging was attempted based on the host tissue reaction and worm morphology. It was arbitrarily classified into early, intermediate and late stages. In general the morphology of the parasite consisted of a well preserved and compact calcospherules with intact subcuticular muscle layer in the early stage, showing a progressive deterioration of parasitic structures, finally undergoing resorptive process or mummification. The host tissue reation in the early stage was characterized by a diffuse epithelioid cell proliferation with lymphocytic and eosinophilic infiltration without capsule formation. The intermediate stage consisted of a diffuse histiocytic proliferation with well formed outer collagen capsule. The latestage revealed mostly thinned out, well collagenized capsule with scanty lymphocytic infiltration. The parasite in the well formed cyst as usually distorted and often mummified. But the hooklets were relatively preserved up to the late stage. These finding suggest that the host tissue reacts to the cysticercus worm in fairly uniform fashion, and this fashion appears to have a sequence, i.e., violent lymphohistiocytic response in the initial phase of infection, and undergoing a gradual fibrotic (encapsulating) self-limiting course, finally being stabilized by a dense, acelluar collagen capsule or collapse and absorption.

[Inflammatory chronic processes of the central nervous system. Neurosurgical aspects]

A study into the neurosurgical approach to thirty-five patients with increased intracranial pressure due to inflamatory diseases affecting the central nervous system and meninges is reported. The entitites under consideration were found to have similar surgical aspects despite the heterogeneity of etiologic agents. As regards the surgical treatment, two groups of cases were recognized. Group 1 comprises 7 patientes with symptoms of a space-occupying lesion; in these patients craniotomies were performed with good results. Group 2 included the remainder 28 cases with acquired hydrocephalus. In this group differents methods for ventricular drainage were used, but ventriculo-auriculostomy and specially ventriculo-peritoneal shunts proved to give more gratifying results. Chemotherapy was administred when the etiologic agent was disclosed. Corticosteroids were institued to reduce inflammatory reations and cerebral edema. A review of the literature supported the practical classification and surgical techniques employed.

[Epilepsy in neurocysticercosis]

Foram estudados 131 casos de epilepsia com etiologia cisticercótica comprovada. A idade variou de 2 a 68 anos; 75 pacientes eram de sexo masculino e 56 de sexo feminino; 117 eram brancos, 10 pardos, três pretos e um amarelo. A idade de início da doença predominou na primeira década. O estudo foi feito em relação ao tipo de epilepsia, ao tempo decorrido após a primeira crise, à freqüência das crises e ao eletrencefalograma relativamente às epilepsias em geral. Investigação foi feita também em relação à cefaléia, aos achados neurológicos, liquóricos, radiológicos simples e contrastados e anátomo-patológicos. A análise dos resultados permitiu aos autores as seguintes conclusões: 1) No grupo de neurocisticercose o início da doença predominou na primeira e a partir da quarta década em relação às epilepsias em geral. 2) Dentre as manifestações clínicas predominaram as formas convulsivas da doença (61%), sendo as crises bravas-jacksonianas as menos freqüentes (4%); quando comparadas com as epilepsias em geral, verifica-se incidência menor das convulsões generalizadas na neurocisticercose. 3) Quanto ao tempo de doença, verifica-se predomínio das formas de duração mais curta (um ano ou menos) na neurocisticercose. 4) A severidade da epilepsia, traduzida pela freqüência das crises, foi menor no grupo com neurocisticercose. 5) Excluídos os casos com anormalidades eletrencefalográficas contínuas, foram encontrados maiores índices percentuais de EEG normal na neurocisticercose que nas epilepsias em geral. 6) A cefaléia estava presente em 68% dos casos, assumindo caráter paroxístico na maior parte (78%); em 67% dos casos com cefaléia paroxística não havia concomitantemente sinais de hipertensão intracraniana; nos casos com cefaléia contínua, em apenas dois (13%) esses sinais não estavam presentes. 7) Na maior parte dos casos (62%) as manifestações epilépticas se apresentaram isoladamente, sem sinais neurológicos focais ou sinais de hipertensão intracraniana.

Imunobiologia da cisticercose: avaliação dos conceitos atuais

O autor procura avaliar os problemas ligados à imunobiologia da cisticercose e os recursos laboratoriais atualmente existentes para o diagnóstico baseando-se, especialmente, em dados sobre a infestação do sistema nervoso central. A análise é conduzida mediante revisão de conhecimentos relacionado à biologia do cisticerco, ao quadro histopatológico por ele desencadeado e às reações biológicas que se patenteiam em exames paraclínicos. Esses fatores são discutidos em relação a aspectos peculiares da doença e orientam as conclusões, entre as quais é apontada a necessidade de estudos mediante experimentação animal e a oportunidade de estudos sobre imunoproteínas para o esclarecimento de pontos ainda duvidosos da patogenia.

Aspectos biológicos da neurocisticercose: alterações do liqüido cefalorraquidiano

Entre os aspectos biológicos da neurocisticercose, têm sido mais exploradas as alterações do líqüido cefalorraquidiano (LCR) em vista do seu valor diagnóstico. Para analisar os conhecimentos quanto ao quadro liquórico da afecção são apresentados 03 achados referentes a 62 caco3 acompanhados na Clínica Neurológica da Faculdade de Medicina da Universidade de São Paulo. Em todos êstes casos a infestação do sistema nervoso central (SNC) e/ou de seus envoltórios pelo cisticerco foi comprovada pela necropsia ou durante intervenção cirúrgica (biopsia). A análise do material e da literatura sôbre o assunto permite as seguintes conclusões: 1 - Entre os exames complementares, o exame do LCR é aquêle que permite com maior freqüência o diagnóstico em vida da neurocisticercose. A demonstração da presença de anticorpos específicos é o elemento fundamental para o diagnóstico liquórico; a ecsinofilorraquia complementa esse dado e tem valor sugestivo. 2 - Na neurocisticercose, a eosinofilorraquia costuma ser tanto mais intensa quanto mais nítida a pleiocitose liquórica; entretanto, a presença de células eosinófilas no LCR pode decorrer' de outras causas e sua ausência não infirma o diagnóstico. A eosinofilorraquia permite avaliar a intensidade da reação hiperérgica desencadeada pelo parasito e possibilita orientar o diagnóstico em casos duvidosos. 3 - Na cisticercose há formação de anticorpos específicos, demonstráveis por meio de reações de precipitação e de fixação do complemento; esta última é a mais largamente utilizada. Os anticorpos são semelhantes aos que aparecem no parasitismo por outros cestóideos. Quando localizados no SNC e/ou em seus envoltórios, são os cisticercos os cestóideos que, com maior freqüência e em maior intensidade, desencadeiam reações imunitárias, determinando o aparecimento de anticorpos específicos no LCR. 4 - A evolução do quadro liquórico é variável e nem sempre acompanha a evolução clínica. Quando esta é satisfatória, costumam desaparecer progressivamente as alterações do LCR; se estas se mantiverem por longo tempo, o prognóstico é mais reservado, especialmente quando aparece hipoglicorraquia. Em alguns casos, após intervenções cirúrgicas há rápida remissão das alterações do LCR; provavelmente isto ocorre nos casos em que a infestação do encéfalo era discreta, ou mesmo única. Quando ocorre rotura da vesícula parasitária durante a intervenção cirúrgica, o liqüido contido em seu interior acarreta exacerbação transitória das alterações do LCR. 5 - As alterações do proteinograma do LCR na neurocisticercose são do tipo verificado em processos inflamatórios subcrônicos e crônicos do SNC e de seus envoltórios, caracterizando-se especialmente por aumento de γ-globulina. Êste aumento está relacionado à intensidade da reação imunopatológica e provavelmente é devido à produção local dessa globulina, que parece ser a carreadora dos anticorpos específicos. O aumento de γ-globulina é precoce, podendo preceder a formação dos anticorpos específicos e costuma regredir lentamente nos casos de evolução satisfatória. Quando a evolução é má, o teor dessa globulina costuma aumentar progressivamente.