Hemorrhagic cerebrovascular events and neurocysticercosis: a case report and review of the literature

Subarachnoid neurocysticercosis presenting as a sudden severe headache

A 46-year-old man, an immigrant from Central America, presented to the emergency department after a motor vehicle collision. He had developed a progressive headache over the previous 48 hours, which had suddenly worsened while driving, causing him to crash. There was no significant head trauma. Clinical and radiological findings prompted a workup for atypical subarachnoid haemorrhage.

Neurosurgical Approach to Neurocysticercosis in Adults: A Comprehensive Systematic Review of Clinical and Imaging Insights

BACKGROUND AND OBJECTIVES

Neurocysticercosis (NCC), caused by larval cysts of Taenia solium, presents a significant health challenge worldwide with diverse clinical presentations and varying management approaches. Untreated NCC can lead to increased intracranial pressure and/or hydrocephalus, with possible death. This review provides comprehensive neurosurgical insight into the heterogeneity of NCC. As there is currently no treatment algorithm for NCC, we propose a framework based on the management strategies most prevalent in the literature.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted searching PubMed, Scopus, and Embase from November 1993 to August 2023. Included articles had individual patient data on the treatments and outcomes of adult patients treated for confirmed symptomatic NCC. Relevant patient data on patient presentations, management, and outcomes and disease characteristics were collected.

RESULTS

Our analysis included 90 studies with 205 patients. Neuroimaging was diagnostic for all, with MRI being predominant (74%). Cysts were intraparenchymal (n = 69), extraparenchymal (n = 68), spinal (n = 24), and mixed distribution (n = 16). Common symptoms included seizures (39%), headache (39%), and motor weakness/paresis (28%). 67 patients presented with hydrocephalus, 30 (45%) of which received a ventriculoperitoneal shunt. NCC was most commonly treated medically with corticosteroids (56%) and albendazole (55%). Neurosurgical intervention was most commonly performed for surgical extraction of cysts (33%). Combination of medical and surgical treatment (98%, 44/45) or surgical intervention alone (98%, 40/41) was the most successful at resolving symptoms after first treatment. Resolution of symptoms with added radiographic resolution of the cyst was common with maximal treatment (n = 137, 70%).

CONCLUSION

NCC's diverse presentations and outcomes emphasize the importance of tailored therapeutic strategies. Limitations of this study include its retrospective nature and low sample sizes of individual studies. The prominence of corticosteroids, albendazole, and surgical procedures highlights their central role in NCC management, as well as the indispensable role of neurosurgeons.

Transcranial Doppler ultrasonography to evaluate cerebral hemodynamic changes in neurocysticercosis

BACKGROUND

 Arteritis is a complication of neurocysticercosis (NCC), which is not well known and could trigger strokes. The transcranial Doppler ultrasound (TCD) is a noninvasive method for detecting, staging, and monitoring cerebrovascular diseases. Nonetheless, the utility of TCD to evaluate cerebral hemodynamic changes, suggesting vasculitis associated with NCC remains uncertain.

OBJECTIVE

 To evaluate cerebral hemodynamic changes using TCD in patients with subarachnoid and parenchymal NCC.

METHODS

 There were 53 patients with NCC evaluated at a reference hospital for neurological diseases included (29 with subarachnoid and 24 with parenchymal). Participants underwent a clinical interview and serology for cysticercosis and underwent TCD performed within 2 weeks of enrollment. Mean flow velocity, peak systolic velocity, end diastolic velocity, and pulsatility index were recorded.

RESULTS

 Among the participants, there were 23 (43.4%) women, with a median age of 37 years (IQR: 29-48). Cerebral hemodynamic changes suggesting vasculitis were detected in 12 patients (22.64%); the most compromised vessel was the middle cerebral artery in 11 (91.67%) patients. There were more females in the group with sonographic signs of vasculitis (10/12, 83.33% vs. 13/41, 31.71%; p = 0.002), and this was more frequent in the subarachnoid NCC group (9/29, 31.03% vs. 3/24, 12.5%; p = 0.187), although this difference did not reach statistical significance.

CONCLUSION

 Cerebral hemodynamic changes suggestive of vasculitis are frequent in patients with NCC and can be evaluated using TCD.

Infectious Causes of Stroke

Stroke is one of the primary causes of mortality and morbidity worldwide. It can be ischemic or hemorrhagic, and the former can be due to an in-situ thrombus or a distant embolus. Despite being a rare cause, stroke can also be caused in the setting of infection. Bacterial agents are the most common cause of stroke, among other infectious agents. Until the antibiotic era, rheumatic heart disease was a predisposing risk factor of infective endocarditis. VZV is the most common cause of strokes in pediatric and adult populations. Cryptococcus and Candida spp are the most common yeasts involved in CNS infections, especially in immunocompromised patients. In COVID-19 patients, ischemic strokes are more common than hemorrhagic strokes. In this review, we will discuss the most common infectious agents, with particular emphasis on COVID-19.

Cerebral cysticercosis mimicking subarachnoid hemorrhage: a case report

BACKGROUND

Dense exudate during the calcification of cerebral cysticercosis in basal subarachnoid space was easy to be misdiagnosed as subarachnoid hemorrhage (SAH); clinical evaluation and MRI can help differentiate SAH from pseudo-SAH.

CASE PRESENTATION

A case of ventricular expansion accompanied by high-density shadows in cisterna circinata cerebri was taken to the hospital for treatment due to sudden faint. This patient was diagnosed as subarachnoid hemorrhage according to computed tomography (CT) in another hospital. We believe that the high density in cisterna circinata cerebri was misdiagnosed as subarachnoid hemorrhage (SAH) 1 year ago. The main etiology of SAH is aneurysm; non-aneurysmal SAH associated with cerebral cysticercosis is extremely rare. Only 5 patients have been reported.

CONCLUSION

This case indicated that although the specificity of CT for SAH is very high, the physicians should be aware of rare false positive findings, called pseudo-SAH.

Subarachnoid neurocysticercosis and an intracranial infectious aneurysm: case report

Infectious intracranial aneurysms (IIAs) represent 2%–6% of all intracranial aneurysms and, classically, have been associated with bacterial or fungal agents. The authors report the case of a 42-year-old woman who presented with a typical history of subarachnoid hemorrhage. Digital subtraction angiography (DSA) showed an aneurysmal dilatation on the frontal M2 segment of the left middle cerebral artery (MCA). The patient was treated surgically, and multiple cysts were found in the left carotid and sylvian cisterns, associated with a dense inflammatory exudate that involved the MCA. The cysts were removed, and a fusiform aneurysmal dilatation was identified. The lesion was not amenable to direct clipping, so the authors wrapped it. Histopathological analysis of the removed cysts revealed the typical pattern of subarachnoid neurocysticercosis. The patient received cysticidal therapy with albendazole and corticosteroids, and she recovered uneventfully. Follow-up DSA performed 6 months after surgery showed complete resolution of the aneurysm. The authors performed a review of the literature and believe that there is sufficient evidence to affirm that the subarachnoid form of neurocysticercosis may lead to the development of an IIA and that Taenia solium should be listed among the possible etiological agents of IIAs, along with bacterial and fungal agents.

Pathogenesis of Taenia solium taeniasis and cysticercosis

Taenia solium infections (taeniasis/cysticercosis) are a major scourge to most developing countries. Neurocysticercosis, the infection of the human nervous system by the cystic larvae of this parasite, has a protean array of clinical manifestations varying from entirely asymptomatic infections to aggressive, lethal courses. The diversity of clinical manifestations reflects a series of contributing factors which include the number, size and location of the invading parasites, and particularly the inflammatory response of the host. This manuscript reviews the different presentations of T. solium infections in the human host with a focus on the mechanisms or processes responsible for their clinical expression.

Clinical management of infectious cerebral vasculitides

A wide range of infections (virus, bacteria, parasite and fungi) may cause cerebral vasculitides. Headache, seizures, encephalopathy and stroke are common forms of presentation. Infection and inflammation of intracranial vessels may cause pathological vascular remodelling, vascular occlusion and ischemia. Vasculitis in chronic meningitis may cause ischemic infarctions, and is associated with poor outcome. Appropriate neuroimaging (CT-angiography, MR-angiography, conventional 4-vessel angiography) and laboratory testing (specific antibodies in blood and CSF, CSF culture and microscopy) and even brain biopsy are needed to quickly establish the aetiology. Enhancement of contrast, wall thickening and lumen narrowing are radiological signs pointing to an infectious vasculitis origin. Although corticosteroids and prophylactic antiplatelet therapy have been used in infectious cerebral vasculitis, there are no randomized clinical trials that have evaluated their efficacy and safety. Stable mycotic aneurysms can be treated with specific antimicrobial therapy. Endovascular therapy and intracranial surgery are reserved for ruptured aneurysms or enlarging unruptured aneurysms.

Infectious causes of stroke

Most infectious pathogens have anecdotal evidence to support a link with stroke, but certain pathogens have more robust associations, in which causation is probable. Few dedicated prospective studies of stroke in the setting of infection have been done. The use of head imaging, a clinical standard of diagnostic care, to confirm stroke and stroke type is not universal. Data for stroke are scarce in locations where infections are probably most common, making it difficult to reach conclusions on how populations differ in terms of risk of infectious stroke. The treatment of infections and stroke, when concomitant, is based on almost no evidence and requires dedicated efforts to understand variations that might exist. We highlight the present knowledge and emphasise the need for stronger evidence to assist in the diagnosis, treatment, and secondary prevention of stroke in patients in whom an infectious cause for stroke is probable.