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Cysticercosis cerebri involving the lateral ventricle
Cysticercosis Cerebri Involving the Lateral Ventricle Zoran Milenkovi~, M.D., Georgi Penev, M.D., Dragan Stojanovie, M.D., Vitomir Jovi~ie, M.D., and Pavle Antovi~, M.D.
Cysticercosis cerebri involving the lateral ventricle is very rare. Two cases with such localization are presented. One of the patients, with occlusion of the foramen of Monro, was successfully treated by operation. A larval form in the lateral ventricle was revealed incidentally at autopsy in the second patient after rupture of a large basilar artery aneurysm. Milenkovi~ Z, Penev G, Stojanovi~ D, Jovi~i~ V, Antovie P: Cysticercosis cerebri involving the lateral ventricle. Surg Neurol 18:94-96, 1982
Cerebral cysticercosis has a worldwide distribution and is frequent in some parts of Asia (China and India), Africa (Egypt), North and South America (Mexico and Chile), and Europe (Poland) [3, 9, 11, 14, 17]. It is also not rare in Yugoslavia [16], although only sporadic cases have been described [8, 16]. Infestation of the central nervous system occurs most frequently as the result of ingestion of food or water contaminated with eggs of Taenia solium. In this event humans can serve as intermediate hosts. If man is a definitive host, self-contamination occurs through the anus-hand-mouth route. Regurgitation of the ova from the gravid proglottids of the adult tapeworm into the patient's stomach is also theoretically possible [9]. Poor hygienic and sanitary conditions and bad habits promote the infection. Well-developed veterinary services, hygienic and sanitary measures, and public health education will help in the elimination of this parasitosis. The human brain is one of the most common organs invaded by cysticerci. These infestations have been described elsewhere [3, 9, 11-13, 16]. There are four essential forms of cerebral cysticercosis: meningeal, ventricular, parenchymal, and mixed [4, 15]. Ventricular localization is a rare form, especially in the lateral ventricles [1, 6, 9, 13]. Two cases involving the lateral ventricles were found during the last five years.
Case Reports Patient 1 A 33-year-old man was admitted to our neurosurgical department in February, 1975, with a history of severe headaches, vomiting, seizures, and right hemiparesis. Ophthalmological examination revealed papilledema. The spinal fluid contained 22 white blood cells per mm a, 184 mg/dl protein, and 7 mg/dl glucose. No eosinophilia was noted in the blood. A left carotid angiogram was made, but only a slight displacement of the left pericallosal artery to the right was found. Pneumoventriculography, however, revealed a marked unilateral hydrocephalus (Fig. 1). A ventriculo. atrial shunt was installed, and two weeks later the patient underwent operation. At operation a bulging, blue cyst, which occluded the foramen of Monro, was seen. It was carefully extracted from the left lateral ventricle. The his. tological finding was cysticercosis cerebri (Fig. 2). The papilledema diminished during the three weeks after the first operation. The patient was continuously treated with anticonvulsant medications, and the frequency of seizures decreased. Postoperatively the patient was seen several times. The last examination was in October, 1980. At that time the patient was having only mild headaches and there had been no seizures for almost two years.
Patient 2 A 32-year-old man was transferred to our department in October, 1975. His chief complaints had begun two weeks before admission and consisted of headaches, dizziness, unsteady gait, and vertiginous disturbances, but almost all symptoms had subsided by admission. At admission he was found to be somnolent with evidence of slight meningeal irritation and a mild right hemiparesis. There were no signs or symptoms of increased intracranial pressure. His optic discs were flat. The left carotid angiogram showed only moderate hydrocephalus. Results of analysis of the cere. brospinal fluid (CSF) were almost normal, with 21 mg/dl of protein content, 60 mg/dl of glucose, and 15 white blood cells per mm a (5 lymphocytes). Suddenly, on the third day after admission, the patient became comatose with irregular From the Ncutosurgical Clinic, University of Nis, Nis, Yugoslavia. respiration. Respiratory arrest came shortly after that. The Author address: Dr. Zoran Milenkovi& Neurosurgical Clinic, University patient was put on mechanical ventilation but died 10 of Nis, 18.000 Nis, Yugoslavia. Key words: cysticercosis cer~bri; seizure; hydrocephalus; foramen of hours after his sudden deterioration. Autopsy findings revealed a ruptured basilar aneurysm, 2 cm in diameter, and a Monro; lateral ventricle.
94 0090.5019/82/080094-03501.25 (~ 1982 by Little, Brown and Company (Inc.)
Milenkovie et al: Ventricular Cysticercosis 95
Fig. 2. Patient l. Part of the germinative membrane of a cysticercosis cyst. (H&E; ×100.)
Fig. 1. Pneumoventriculograms show an asymmetrical hydrocephalus with the cyst in the lateral ventricle.
solid, larval form of cysticerci in the left lateral ventricle (Fig. 3). Discussion Cysticercosis of the brain is a parasitic disease found mostly in areas where the organism is endemic [12, 13]. The symptoms are not highly specific and can be manifested as: symptoms and signs of increased intracranial pressure, focal symptoms, seizures, and signs of mental disturbances [2, 6, 12-15, 17]. Several months to 20 years can pass from the time of the infestation to the appearance of the first clinical symptoms [9], but the average interval is probably 2 to 5 years [14]. Spinal fluid findings, such as pleocytosis, eosinophilia, high protein level, and reduced glucose content, hint at possible cerebral cysticercosis [7-9, 17]. Com-
Fig. 3. Patient 2. The larval stage of the parasite in the lateral ventricle. (H&E; × lO0.)
plement fixation and precipitation tests are positive in 80 to 97% of the cases [3, 7, 12]. All these findings in the CSF are more constant in the spinal fluid than in the ventricular fluid, as is also the case with ventriculosubarachnoid varieties, but less so with the parenchymal ones [7]. The purified protein derivative skin test and the cerebrospinal
96
Surgical Neurology Vol 18 No 2 August 1982
venereal disease test are not typical of cysticercosis [12]. Some serological tests have also been described [91, but negative results cannot be considered to rule out the infestation. Intracranial calcifications; calcifications of the soft tissues of the neck, chest, and abdomen; and the presence of subcutaneous cysts have also been considered typical signs of cysticercosis [2, 4, 13-151. A unilateral, asymmetrical hydrocephalus confirmed by pneumoventriculography can be a very important sign of cerebral involvement by this parasite [9]. However, in the vast majority of cases, the diagnosis of cysticercosis cerebri is made intraoperatively or at postmortem examination. The information provided by computerized tomography is beneficial as well [3]. Intraventricular cysticercosis is a rare form of this disease [6], especially in the lateral ventricles [9, 10, 15, 16]. Escobar and Nieto [51 and King and Hosobuchi [9] have stated that cysticercosis in the lateral ventricles is the rarest form of cerebral cysticercosis. A m o n g 132 patients with cerebral cysticercosis in Stepien's series [17] treated by operation, only two cysts were found in the lateral ventricles. Asenjo and associates [11 argued that the intraventricular form of cysticercosis is found usually in the fourth ventricle. The parasites in the ventricles may be single or multiple, and free in the CSF (Patient 2), or attached to the wall of the cavity (Patient 1). Mature forms are most common, but occasionally immature forms are found. They may be 3 to 4 mm in diameter [41. The larval form, as was observed in Patient 2, is commonly called a bladder worm [11]. Extirpation of the cyst from the lateral ventricle is possible and several reports have discussed this [9, 10, 15, 17]. The removal of the intraventricular cyst by gentle aspiration, such as with a pipette, may also be successful [10].
References 1. AsenjoA, DonosoP, ColinE:Tumeursventriculairespeufr~quentes. Neutochirurgie 19:308-312, 1973 2. Borne G, Arnoud B, Bedou G, Aresu PJ: La cysticercosec~t~bra[: a propos de 2 cas d'infestation intra-parenchymateuse diss~min~. Neurochirurgie 24:129-132, 1978 3. Carbajal JR, Palacios E, Azar-Kia B, Churchill R: Radiologyof cysticercosis of the central nervous system including computed tomography. Radiology 125:127-131, 1977 4. C~irdenas JCY: Cysticercosis of the nervous system. Pathologic and radiologic findings. J Neurosurg 19:635-640, 1962 5. EscobarA, Nieto D: Parasitic diseases, in Minkler J (ed): Pathologyof the Nervous System. New York: McGraw-Hill, Vol 3, 1972, pp 2503-2521 6. Fabiani A, Torty R, Trebini F: Cysticercosisof the fourth ventricle. Schweiz Arch Neurol Neurochir Psychiatr 123:171-177, 1978 7. G6ni PB: Cysticercosisof the nervous system: clinical findings and treatment. J Neurosurg 19:505-513, 1962 8. Kaljovie R, Marinkovie V, Margetie V: Cisticerkoza mozga. Vojnosanit Pregl 34:99-101, 1977 9. King JS, Hosobuchi Y: Cysticercus cyst of the lateral ventricle. Surg Neurol 7:125-129, 1977 10. Madrazo NI, Sanchez Cabrera JM, Leon JAM: Pipette suction for atraumatic extraction of intraventricular cysticercosis cyst. J Neurosurg 50:531- 532, 1979 11. Oliv~ JI, Angulio-Rivero P: Cysticercosisof the nervous system: introduction and general aspects. J Neurosurg 19:632-634, 1962 12. Poon TR, Aride EJ, Tyschenko WR: Cerebral cysticercosis with aqueductal obstruction. J Neurosurg 53:252-255, 1980 13. ReyesV, EscuetaAV: Parasitic diseasesof the central nervoussystem, in Goldensohn ES, Appel SA (eds): Scientific Approachesto Clinical Neurology. Philadelphia: Lea & Febinger, Vol 1, 1977, pp 498-514 14. Simms NM, Maxwell RE, Christiansen PC, French LA: Internal hydrocephalus secondary to cysticercosis cerebri: treatment with ventriculoatrial shunt. J Neurosurg 30:305-309, 1969 15. Siqeira EB, Richardson RP, Kranzler Lh Cysticercosis cerebri occluding the foramen of Monro. Surg Neutol 13:429-431, 1980 16. Skender M, Cvetkovie D, Rakie S, Jovanovie V, Dogie S: Histopatolo~ke promene u cerebralne cisticerkoze. Srpski Arhiv 6:581590, 1979 17. Stepien L: Cerebral cysticercosis in Poland. Clinical symptoms and operative results in 132 cases. J Neurosurg 19:505-513, 1962
Book Review AMA Manual for Authors & Editors: Editorial Style and Manuscript Preparation Compiled for the American Medical Association Los Altos, CA, Lange Medical Publications, 1981
tions will vary for other journals, they are insignificant and can usually be obtained from the instructions to authors sections that most journals publish. All authors of medical and scientific papers can benefit 184 pp., $8.50 from this book. Authors preparing papers for the first time should read it carefully, and more or less completely. All Reviewed by Paul C. Bucy, M.D., Editor authors will find it to be a very valuable reference, while all This book was prepared to guide authors in the preparation editors hope that those who submit papers will use this book of manuscripts for publication in the journals of the A M A . frequently. Doing so will greatly lessen their work and will Although there are minor points on which these instruc- make papers submitted more readily acceptable.
Cysticercosis cerebri involving the lateral ventricle is very rare. Two cases with such localization are presented. One of the patients, with occlusion of the foramen of Monro, was successfully treated by operation. A larval form in the lateral ventricle was revealed incidentally at autopsy in the second patient after rupture of a large basilar artery aneurysm. Milenkovi~ Z, Penev G, Stojanovi~ D, Jovi~i~ V, Antovie P: Cysticercosis cerebri involving the lateral ventricle. Surg Neurol 18:94-96, 1982
Cerebral cysticercosis has a worldwide distribution and is frequent in some parts of Asia (China and India), Africa (Egypt), North and South America (Mexico and Chile), and Europe (Poland) [3, 9, 11, 14, 17]. It is also not rare in Yugoslavia [16], although only sporadic cases have been described [8, 16]. Infestation of the central nervous system occurs most frequently as the result of ingestion of food or water contaminated with eggs of Taenia solium. In this event humans can serve as intermediate hosts. If man is a definitive host, self-contamination occurs through the anus-hand-mouth route. Regurgitation of the ova from the gravid proglottids of the adult tapeworm into the patient's stomach is also theoretically possible [9]. Poor hygienic and sanitary conditions and bad habits promote the infection. Well-developed veterinary services, hygienic and sanitary measures, and public health education will help in the elimination of this parasitosis. The human brain is one of the most common organs invaded by cysticerci. These infestations have been described elsewhere [3, 9, 11-13, 16]. There are four essential forms of cerebral cysticercosis: meningeal, ventricular, parenchymal, and mixed [4, 15]. Ventricular localization is a rare form, especially in the lateral ventricles [1, 6, 9, 13]. Two cases involving the lateral ventricles were found during the last five years.
Case Reports Patient 1 A 33-year-old man was admitted to our neurosurgical department in February, 1975, with a history of severe headaches, vomiting, seizures, and right hemiparesis. Ophthalmological examination revealed papilledema. The spinal fluid contained 22 white blood cells per mm a, 184 mg/dl protein, and 7 mg/dl glucose. No eosinophilia was noted in the blood. A left carotid angiogram was made, but only a slight displacement of the left pericallosal artery to the right was found. Pneumoventriculography, however, revealed a marked unilateral hydrocephalus (Fig. 1). A ventriculo. atrial shunt was installed, and two weeks later the patient underwent operation. At operation a bulging, blue cyst, which occluded the foramen of Monro, was seen. It was carefully extracted from the left lateral ventricle. The his. tological finding was cysticercosis cerebri (Fig. 2). The papilledema diminished during the three weeks after the first operation. The patient was continuously treated with anticonvulsant medications, and the frequency of seizures decreased. Postoperatively the patient was seen several times. The last examination was in October, 1980. At that time the patient was having only mild headaches and there had been no seizures for almost two years.
Patient 2 A 32-year-old man was transferred to our department in October, 1975. His chief complaints had begun two weeks before admission and consisted of headaches, dizziness, unsteady gait, and vertiginous disturbances, but almost all symptoms had subsided by admission. At admission he was found to be somnolent with evidence of slight meningeal irritation and a mild right hemiparesis. There were no signs or symptoms of increased intracranial pressure. His optic discs were flat. The left carotid angiogram showed only moderate hydrocephalus. Results of analysis of the cere. brospinal fluid (CSF) were almost normal, with 21 mg/dl of protein content, 60 mg/dl of glucose, and 15 white blood cells per mm a (5 lymphocytes). Suddenly, on the third day after admission, the patient became comatose with irregular From the Ncutosurgical Clinic, University of Nis, Nis, Yugoslavia. respiration. Respiratory arrest came shortly after that. The Author address: Dr. Zoran Milenkovi& Neurosurgical Clinic, University patient was put on mechanical ventilation but died 10 of Nis, 18.000 Nis, Yugoslavia. Key words: cysticercosis cer~bri; seizure; hydrocephalus; foramen of hours after his sudden deterioration. Autopsy findings revealed a ruptured basilar aneurysm, 2 cm in diameter, and a Monro; lateral ventricle.
94 0090.5019/82/080094-03501.25 (~ 1982 by Little, Brown and Company (Inc.)
Milenkovie et al: Ventricular Cysticercosis 95
Fig. 2. Patient l. Part of the germinative membrane of a cysticercosis cyst. (H&E; ×100.)
Fig. 1. Pneumoventriculograms show an asymmetrical hydrocephalus with the cyst in the lateral ventricle.
solid, larval form of cysticerci in the left lateral ventricle (Fig. 3). Discussion Cysticercosis of the brain is a parasitic disease found mostly in areas where the organism is endemic [12, 13]. The symptoms are not highly specific and can be manifested as: symptoms and signs of increased intracranial pressure, focal symptoms, seizures, and signs of mental disturbances [2, 6, 12-15, 17]. Several months to 20 years can pass from the time of the infestation to the appearance of the first clinical symptoms [9], but the average interval is probably 2 to 5 years [14]. Spinal fluid findings, such as pleocytosis, eosinophilia, high protein level, and reduced glucose content, hint at possible cerebral cysticercosis [7-9, 17]. Com-
Fig. 3. Patient 2. The larval stage of the parasite in the lateral ventricle. (H&E; × lO0.)
plement fixation and precipitation tests are positive in 80 to 97% of the cases [3, 7, 12]. All these findings in the CSF are more constant in the spinal fluid than in the ventricular fluid, as is also the case with ventriculosubarachnoid varieties, but less so with the parenchymal ones [7]. The purified protein derivative skin test and the cerebrospinal
96
Surgical Neurology Vol 18 No 2 August 1982
venereal disease test are not typical of cysticercosis [12]. Some serological tests have also been described [91, but negative results cannot be considered to rule out the infestation. Intracranial calcifications; calcifications of the soft tissues of the neck, chest, and abdomen; and the presence of subcutaneous cysts have also been considered typical signs of cysticercosis [2, 4, 13-151. A unilateral, asymmetrical hydrocephalus confirmed by pneumoventriculography can be a very important sign of cerebral involvement by this parasite [9]. However, in the vast majority of cases, the diagnosis of cysticercosis cerebri is made intraoperatively or at postmortem examination. The information provided by computerized tomography is beneficial as well [3]. Intraventricular cysticercosis is a rare form of this disease [6], especially in the lateral ventricles [9, 10, 15, 16]. Escobar and Nieto [51 and King and Hosobuchi [9] have stated that cysticercosis in the lateral ventricles is the rarest form of cerebral cysticercosis. A m o n g 132 patients with cerebral cysticercosis in Stepien's series [17] treated by operation, only two cysts were found in the lateral ventricles. Asenjo and associates [11 argued that the intraventricular form of cysticercosis is found usually in the fourth ventricle. The parasites in the ventricles may be single or multiple, and free in the CSF (Patient 2), or attached to the wall of the cavity (Patient 1). Mature forms are most common, but occasionally immature forms are found. They may be 3 to 4 mm in diameter [41. The larval form, as was observed in Patient 2, is commonly called a bladder worm [11]. Extirpation of the cyst from the lateral ventricle is possible and several reports have discussed this [9, 10, 15, 17]. The removal of the intraventricular cyst by gentle aspiration, such as with a pipette, may also be successful [10].
References 1. AsenjoA, DonosoP, ColinE:Tumeursventriculairespeufr~quentes. Neutochirurgie 19:308-312, 1973 2. Borne G, Arnoud B, Bedou G, Aresu PJ: La cysticercosec~t~bra[: a propos de 2 cas d'infestation intra-parenchymateuse diss~min~. Neurochirurgie 24:129-132, 1978 3. Carbajal JR, Palacios E, Azar-Kia B, Churchill R: Radiologyof cysticercosis of the central nervous system including computed tomography. Radiology 125:127-131, 1977 4. C~irdenas JCY: Cysticercosis of the nervous system. Pathologic and radiologic findings. J Neurosurg 19:635-640, 1962 5. EscobarA, Nieto D: Parasitic diseases, in Minkler J (ed): Pathologyof the Nervous System. New York: McGraw-Hill, Vol 3, 1972, pp 2503-2521 6. Fabiani A, Torty R, Trebini F: Cysticercosisof the fourth ventricle. Schweiz Arch Neurol Neurochir Psychiatr 123:171-177, 1978 7. G6ni PB: Cysticercosisof the nervous system: clinical findings and treatment. J Neurosurg 19:505-513, 1962 8. Kaljovie R, Marinkovie V, Margetie V: Cisticerkoza mozga. Vojnosanit Pregl 34:99-101, 1977 9. King JS, Hosobuchi Y: Cysticercus cyst of the lateral ventricle. Surg Neurol 7:125-129, 1977 10. Madrazo NI, Sanchez Cabrera JM, Leon JAM: Pipette suction for atraumatic extraction of intraventricular cysticercosis cyst. J Neurosurg 50:531- 532, 1979 11. Oliv~ JI, Angulio-Rivero P: Cysticercosisof the nervous system: introduction and general aspects. J Neurosurg 19:632-634, 1962 12. Poon TR, Aride EJ, Tyschenko WR: Cerebral cysticercosis with aqueductal obstruction. J Neurosurg 53:252-255, 1980 13. ReyesV, EscuetaAV: Parasitic diseasesof the central nervoussystem, in Goldensohn ES, Appel SA (eds): Scientific Approachesto Clinical Neurology. Philadelphia: Lea & Febinger, Vol 1, 1977, pp 498-514 14. Simms NM, Maxwell RE, Christiansen PC, French LA: Internal hydrocephalus secondary to cysticercosis cerebri: treatment with ventriculoatrial shunt. J Neurosurg 30:305-309, 1969 15. Siqeira EB, Richardson RP, Kranzler Lh Cysticercosis cerebri occluding the foramen of Monro. Surg Neutol 13:429-431, 1980 16. Skender M, Cvetkovie D, Rakie S, Jovanovie V, Dogie S: Histopatolo~ke promene u cerebralne cisticerkoze. Srpski Arhiv 6:581590, 1979 17. Stepien L: Cerebral cysticercosis in Poland. Clinical symptoms and operative results in 132 cases. J Neurosurg 19:505-513, 1962
Book Review AMA Manual for Authors & Editors: Editorial Style and Manuscript Preparation Compiled for the American Medical Association Los Altos, CA, Lange Medical Publications, 1981
tions will vary for other journals, they are insignificant and can usually be obtained from the instructions to authors sections that most journals publish. All authors of medical and scientific papers can benefit 184 pp., $8.50 from this book. Authors preparing papers for the first time should read it carefully, and more or less completely. All Reviewed by Paul C. Bucy, M.D., Editor authors will find it to be a very valuable reference, while all This book was prepared to guide authors in the preparation editors hope that those who submit papers will use this book of manuscripts for publication in the journals of the A M A . frequently. Doing so will greatly lessen their work and will Although there are minor points on which these instruc- make papers submitted more readily acceptable.