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An unusual cause of a midbrain syndrome
Journal of Clinical Neuroscience 18 (2011) 162
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images in Neuroscience: Answer
An unusual cause of a midbrain syndrome Sanjeev Jha ⇑, M.K. Ansari, K.K. Sonkar, Vimal K. Paliwal Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226 014, Uttar Pradesh, India
1. Answer C. Weber’s syndrome secondary to neurocysticercosis. Note the prominent scolex on the MRI (Fig. 1b of Images in Neuroscience: Question). Visualization of the scolex by MRI, or as an eccentric calcified dot on a CT scan, is characteristic of NCC. 2. Discussion Weber’s syndrome is a well-defined midbrain lacunar stroke syndrome. It is also well described with neurocysticercosis (NCC). Thrombosis of superficial cortical vessels due to the chronic meningitis associated with NCC, or occlusion of small perforating vessels affected by endarteritis, can cause Weber’s syndrome secondary to NCC.1,2 Other mechanisms suggested include an inflammatory reaction that accompanies the death of the parasite, resulting in edema and mass effect.3,4 The severity of cerebrovascular complications of NCC is related to the distribution of the cysticerci in the brain and the severity of the accompanying
DOI of question: 10.1016/j.jocn.2009.11.038
⇑ Corresponding author. Tel.: +91 522 2668004–08; fax: +91 522 2668017. E-mail addresses: [email protected], [email protected] (S. Jha). 0967-5868/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2009.11.040
arachnoiditis. Inflammatory injury of the brain parenchyma may be responsible for the clinical picture of Weber’s syndrome in our patient.5,6 The patient recovered completely with conservative management. It is important to be aware of rare presentations of common diseases to prevent erroneous diagnosis and delay in management.
References 1. Lath R, Rajshekhar V. Solitary cysticercus granuloma of the brainstem. J Neurosurg 1998;89:1047–51. 2. Liu CT, Cremer CW, Logigian EL. Midbrain syndromes of Benedict, Claude, and Nothnagel – setting the record straight. Neurology 1992;42:1820–2. 3. Garcia HH, Gonzalez AE, Evains CA, et al. Taenia solium cysticercosis. Lancet 2003;362:547–56. 4. Jha S, Kumar V. Neurocysticercosis presenting as stroke. Neurol India 2000;48:391–4. 5. Kim JS, Jeong SM, Moon SY, et al. Third cranial nerve palsy from midbrain neurocysticercosis: repeated exacerbation on tapering corticosteroids. J Neuroophthalmol 2004;24:217–20. 6. Singh NN, Verma R, Pankaj BK, et al. Neurocysticercosis presenting as Weber’s syndrome. Neurol India 2003;51:551–2.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images in Neuroscience: Answer
An unusual cause of a midbrain syndrome Sanjeev Jha ⇑, M.K. Ansari, K.K. Sonkar, Vimal K. Paliwal Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226 014, Uttar Pradesh, India
1. Answer C. Weber’s syndrome secondary to neurocysticercosis. Note the prominent scolex on the MRI (Fig. 1b of Images in Neuroscience: Question). Visualization of the scolex by MRI, or as an eccentric calcified dot on a CT scan, is characteristic of NCC. 2. Discussion Weber’s syndrome is a well-defined midbrain lacunar stroke syndrome. It is also well described with neurocysticercosis (NCC). Thrombosis of superficial cortical vessels due to the chronic meningitis associated with NCC, or occlusion of small perforating vessels affected by endarteritis, can cause Weber’s syndrome secondary to NCC.1,2 Other mechanisms suggested include an inflammatory reaction that accompanies the death of the parasite, resulting in edema and mass effect.3,4 The severity of cerebrovascular complications of NCC is related to the distribution of the cysticerci in the brain and the severity of the accompanying
DOI of question: 10.1016/j.jocn.2009.11.038
⇑ Corresponding author. Tel.: +91 522 2668004–08; fax: +91 522 2668017. E-mail addresses: [email protected], [email protected] (S. Jha). 0967-5868/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2009.11.040
arachnoiditis. Inflammatory injury of the brain parenchyma may be responsible for the clinical picture of Weber’s syndrome in our patient.5,6 The patient recovered completely with conservative management. It is important to be aware of rare presentations of common diseases to prevent erroneous diagnosis and delay in management.
References 1. Lath R, Rajshekhar V. Solitary cysticercus granuloma of the brainstem. J Neurosurg 1998;89:1047–51. 2. Liu CT, Cremer CW, Logigian EL. Midbrain syndromes of Benedict, Claude, and Nothnagel – setting the record straight. Neurology 1992;42:1820–2. 3. Garcia HH, Gonzalez AE, Evains CA, et al. Taenia solium cysticercosis. Lancet 2003;362:547–56. 4. Jha S, Kumar V. Neurocysticercosis presenting as stroke. Neurol India 2000;48:391–4. 5. Kim JS, Jeong SM, Moon SY, et al. Third cranial nerve palsy from midbrain neurocysticercosis: repeated exacerbation on tapering corticosteroids. J Neuroophthalmol 2004;24:217–20. 6. Singh NN, Verma R, Pankaj BK, et al. Neurocysticercosis presenting as Weber’s syndrome. Neurol India 2003;51:551–2.