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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1873-1875

Vesicular Stage Cysticercosis of Midbrain Posing a Clinical Ambiguity


1 Department of Neurosurgery, KMC, Manipal, Karnataka, India
2 Department of Neurosurgery, CMC, Vellore, Tamil Nadu, India
3 Department of Radiology, CMC, Vellore, Tamil Nadu, India
4 Department of Pathology, CMC, Vellore, Tamil Nadu, India

Date of Submission17-Dec-2019
Date of Decision08-Feb-2020
Date of Acceptance07-Aug-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. R Krishnaprabhu
Department of Neurosurgery, CMC, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333438

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How to cite this article:
Nayak R, Krishnaprabhu R, Mani S, Patel B. Vesicular Stage Cysticercosis of Midbrain Posing a Clinical Ambiguity. Neurol India 2021;69:1873-5

How to cite this URL:
Nayak R, Krishnaprabhu R, Mani S, Patel B. Vesicular Stage Cysticercosis of Midbrain Posing a Clinical Ambiguity. Neurol India [serial online] 2021 [cited 2022 Jan 19];69:1873-5. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1873/333438




Dear Sir,

A 44-year-old lady presented to us with the complaints of progressive restriction of movements of left eye and weakness of the right side of the body for the last six months. Examination revealed a complete third nerve palsy in the left eye, right spastic hemiparesis, and right upper motor neuron (UMN) facial paresis.

Magnetic resonance imaging (MRI) of the brain with Gadolinium showed a well-defined, intra-axial, lobulated, spectated, partially exophytic, and cystic lesion measuring 24 × 19.8 × 25 mm in the left thalamo-mesencephalic region, involving the cerebral peduncle and midbrain. Inferiorly, it was seen abutting the superior surface of the pons. The lesion was T1 hypointense, T2 hyperintense with no enhancing solid component or walls. No restriction on diffusion-weighted imaging (DWI) or blooming on susceptibility-weighted imaging (SWI) [Figure 1]. The possibility of a thalamo-mesencephalic cyst, pilocytic astrocytoma, or hemangioblastoma was considered. A parasitic cyst although considered, the increasing symptoms and the large size (>2 cm) and lack of edema made it a less likely possibility.
Figure 1: MRI brain showing a cystic lesion in the left side of midbrain. (a) T1 hypo intense (coronal section), (b) T2 hyper intense (axial section), (c) Non enhancing (sagittal section with gadolinium contrast) and (d) No restriction on diffusion-weighted imaging (DWI)

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Considering the progressive neurological deficits and the ambiguous nature of the mass, surgical excision was planned [Figure 1]. Histopathology was suggestive of cysticercosis [Figure 2].
Figure 2: Intraoperative images (a and b). 2A: II. Optic nerve, III. Oculomotor nerve, IC. Internal carotid artery, A. Cyst with arachnoid layer bulging into the crural cistern. 2B: C. Cysticercus cyst, B. Basilar artery, M1: Middle cerebral artery, I. Instrument holding the cyst wall, S. Suction apparatus. Histopathology images (c and d). Hematoxylin and eosin stained sections shows a cyst of cysticercosis comprising of outer wavy cuticular layer and cellular layer beneath. The inner most layer is reticular and contains tubules. A. 100×, B. 200×

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Isolated brainstem cysticercosis is a rare clinical entity which creates a diagnostic dilemma as the clinical and imaging features might be identical to the other brainstem lesions.[1] A vesicular type of SCG is rarest among them; only four cases have been reported till now to the best of our knowledge[2] [Table 1].[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27]
Table 1: Review of literature including both vesicular and colloidal stages of solitary brainstem cysticercosis

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There are four pathological stages of cysticercosis (vesicular, colloidal vesicular, granular nodular, and nodular) which have been well correlated with the imaging.[3] Vesicular stage is the initial stage when the larva is alive but on imaging looks like a cyst without any enhancement but sometimes with an eccentric scolex (cyst with a dot sign).

Treatment of the disease depends both on clinical and radiological features. A solitary brainstem cyst with nonprogressive symptoms measuring less than 20 mm in size can be managed by closed clinical and radiological monitoring. A trial of tablet albendazole, a cysticidal drug, 15 mg/kg/day for 3 days might be effective.[4] In case of any clinical or radiological deterioration surgical intervention might be considered.

Although isolated brain stem cysticercosis is a rare clinical entity, it should be considered in the differential diagnosis of a purely cystic lesion in the brainstem, especially in an endemic country like India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Lath R, Rajshekhar V. Solitary cysticercus granuloma of the brainstem: Report of four cases. J Neurosurg 1998;89:1047-51.  Back to cited text no. 1
    
2.
Del Brutto OH, Del Brutto VJ. Isolated brainstem cysticercosis: A review. Clin Neurol Neurosurg 2013;115:507-11.  Back to cited text no. 2
    
3.
Kimura-Hayama ET, Higuera JA, Corona-Cedillo R, Chávez-Macías L, Perochena A, Quiroz-Rojas LY, et al. Neurocysticercosis: Radiologic-pathologic correlation. Radiographics 2010;30:1705-19.  Back to cited text no. 3
    
4.
Bustos JA, Pretell EJ, Llanos-Zavalaga F, Gilman RH, Del Brutto OH, Garcia HH. Efficacy of a 3-day course of albendazole treatment in patients with a single neurocysticercosis cyst. Clin Neurol Neurosurg 2006;2:193-4.  Back to cited text no. 4
    
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Ranjith MP, Divya R, Sahni A. Isolated one and a half syndrome: An atypical presentation of neurocysticercosis. Indian J Med Sci 2009;63:119-20.  Back to cited text no. 18
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Chotmongkol V, Sawanyawisuth K, Limpawattana P, Phuphatham A, Chotmongkol R, Intapan PM. Superior divisional oculomotor nerve palsy caused by midbrain neurocysticercosis. Parasitol Int 2006;55:223-5.  Back to cited text no. 23
    
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