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 »  Introduction
 »  Case reports
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Year : 2000  |  Volume : 48  |  Issue : 1  |  Page : 85-7

Enlarging single CT lesions can also spontaneously resolve.


Randhir Singh Nagar, Ludhiana, Punjab, India.

Correspondence Address:
Randhir Singh Nagar, Ludhiana, Punjab, India.

  »  Abstract

Computed tomography in two patients, aged 9 and 14 years, with history of focal seizures, revealed single, small, enhancing CT lesions. These patients were treated with albendazole and anticonvulsants. Follow-up CT scans revealed an increase in the size of the solitary lesions. They were managed conservatively and further follow-up CT scans revealed complete resolution of the lesions. The report suggests that some enlarging CT lesions may also spontaneously resolve. The most likely cause of the enlarging lesions was albendazole therapy.

How to cite this article:
Singh G, Sobti P, Bhatia R S, Singh D. Enlarging single CT lesions can also spontaneously resolve. Neurol India 2000;48:85


How to cite this URL:
Singh G, Sobti P, Bhatia R S, Singh D. Enlarging single CT lesions can also spontaneously resolve. Neurol India [serial online] 2000 [cited 2020 Aug 11];48:85. Available from: http://www.neurologyindia.com/text.asp?2000/48/1/85/1466




   »   Introduction Top

An involuting single parenchymal cysticercus cyst is often the basis of focal seizures with or without secondary generalization in young patients in the Indian subcontinent.[1] These solitary cysticercus granulomas have been reported as 'disappearing CT lesions', 'vanishing CT lesions' or more appropriately 'single, small (<10mm), enhancing CT lesions'.[2],[3],[4] The majority of these single lesions disappear on follwup CT scans performed 12-16 weeks after the initial imaging study. Chandy et al reported results of stereotaxic guided excision biopsies in single enhancing CT lesions that did not resolve at the 12 weeks time period.[5] A cysticercus granuloma was found to underlie 80% of the lesions. The histology was inconclusive in the remainder 20% of the lesions studied. At present, it is widely accepted that cysticercosis is responsible for the overwhelming majority of the single enhancing CT lesions that spontaneously resolve within 12-16 weeks.[6] We report two patients with single CT lesions that actually enlarged on follow-up CT scans and finally resolved without any specific therapy.


   »   Case reports Top

Case 1: A 7 years old boy had left focal seizures with secondary generalisation six weeks before presenting to the Neurology clinic. During this six week period, he had a CT scan done in a private hospital, which revealed the presence of a single small enhancing CT lesion in the right parieto-occipital region [Figure 1a]. Subsequently, the boy was treated with carbamezapine and albendazole (15 mg/kg body weight/day for a period of 21 days). Just prior to presentation in our OPD, another CT scan was ordered. This CT scan revealed definite enlargement of the lesion in the right parieto-occipital region [Figure 1b]. A stereotaxic excision biopsy was refused by the patient. It was decided to observe the lesion for a period of another six weeks. Meanwhile, oral glycerol, furosemide and acetazolamide were administered to the patient. The imaging study was repeated six weeks later and this showed complete disappearance of the lesion [Figure 1c].
Case 2: A 14 years old male developed seizures 3 months before admission. The seizures comprised of a visual aura followed by loss of consciousness. A CT scan revealed a left occipital single small enhancing CT lesion. He was started on albendazole therapy by a practicing neurologist. A CT scan was repeated, 2 months after the onset of seizures and this showed definite enlargement of the lesion in the form of a widened ring of contrast enhancement and a greater amount of surrounding oedema. Upon his first visit to our clinic, 3 months after the seizures, another CT scan was ordered. This CT scan showed that there was a spec of calcification, no contrast uptake and no surrounding oedema.


   »   Discussion Top

Enlarging single CT lesions have been described in the literature under the rubric 'enlarging cysticercus granulomas'.[7] This paper adds 2 more cases of enlarging lesions that were probably involuting cysticercus cysts. Rajshekhar and Chandy postulated two mechanisms for the enlargement of the cysticercus granulomas.[7] One was simply an increasing amount of inflammatory reaction giving rise to an increase in the size of the ring enhancing lesion as well as the surrounding oedema. The second mechanism involved two cysticercus cysts located in proximity to each other, the degeneration of one following the other very closely. The increasing size of the lesions observed by us is probably explicable on the basis of the first postulate.
Rajshekhar and Chandy, based on their experience of 3 patients, suggested that the enlarging cysticercus granulomas may be conservatively managed with a trial of albendazole therapy.[7] On the contrary, we believe that albendazole therapy was the cause of enlargement of the CT lesions observed by us. Expectedly, albendazole administration would accelerate involution of a cysticercus granuloma, thereby leading to increasing inflammation around the granuloma. This would appear on the CT scan as an enlarging lesion. The resolution observed by Rajshekhar and Chandy, in 3 of their cases could be merely fortuitous and it is likely that the lesions would have spontaneously resolved had they not been treated with albendazole.[7]
Both patients in this communication did not report worsening of the neurological deficit or an increasing seizure frequency as a result of the enlarging lesions. Therefore it is best to treat these patients with anticonvulsant alone. At the same time it may be stressed that enlarging lesions presumed to be of cysticercal origin, form only a small proportion of enlarging single CT lesions and conditions like tuberculomas and primary or secondary tumours should be considered foremost among the diagnostic possibilities.[8] The most likely cause of the enlargement in the two patients in the present communication is inadvertent cysticidal therapy.
 

  »   References Top

1.Gagandeep Singh: Cysticercosis in South Central America and the Indian subcontinent. A comparative evaluation. Arq Neuropsiquitr 1997; 55: 349-356.   Back to cited text no. 1    
2.Ahuja GK, Behari M, Prasad K et al: Disappearing CT lesions in epilepsy. Is cysticercosis or tuberculosis the cause. J Neurol Neurosurg Psychiatry 1989; 52: 915916.   Back to cited text no. 2    
3.Chopra JS, Sawhney IMS, Suresh N et al: Vanishing CT lesions in epilepsy. J Neurol Sci 1992; 107: 40-49.   Back to cited text no. 3    
4.Chandy MJ, Rajshekhar V, Ghosh S et al: Single, small, enhancing CT lesions in Indian patients with epilepsy. Clinical radiological and pathological considerations. J Neurol Neurosurg Psychiatry 1991; 54: 702-705.   Back to cited text no. 4    
5.Chandy MJ, Rajshekhar V, Prakash S et al: Cysticercosis causing single, small, enhancing CT lesions in Indian patients with seizures. Lancet 1989; (I): 390-391.   Back to cited text no. 5    
6.Rajshekhar V: Etiology and management of single small CT lesions in patients with seizures. Understanding a controversy. Acta Neurol Scand 1991; 84: 465-470.   Back to cited text no. 6    
7.Rajshekhar V, Chandy MJ: Enlarging solitary cysticercus granulomas. J Neurosurg 1994; 80: 840-843.   Back to cited text no. 7    
8.Rajshekhar V, Haran RP, Prakash S: Differentiating solitary small cysticercus granulomas and tuberculomas in patients with epilepsy. Clinical and Computerized tomographic criteria. J Neurosurg 1993; 78: 402-407.   Back to cited text no. 8    

 

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