PDF icon PDF herunterladen
Open Access
CC BY-NC-ND 4.0 · Indian Journal of Neurosurgery 2022; 11(03): 271-273
DOI: 10.1055/s-0041-1722833
Short Communication

Lumbar Subarachnoid Neurocysticercosis: A Case Report with Literature Review

Kanakam Chandrakanth
1   Department of Neurosurgery, Yashoda Hospital, Secundrabad, Telangana, India
,
Krishna Kumar G. 
1   Department of Neurosurgery, Yashoda Hospital, Secundrabad, Telangana, India
,
Ravi Suman Reddy
1   Department of Neurosurgery, Yashoda Hospital, Secundrabad, Telangana, India
,
Kartik Manoj Multani
1   Department of Neurosurgery, Yashoda Hospital, Secundrabad, Telangana, India
› Institutsangaben
› Weitere Informationen
Auch verfügbar aufeRefMedOne
 
 als PDF herunterladen Lizenzen und Reprints

Abstract

Neurocysticercosis (NCC) is the most common parasitic infection of brain. Spinal NCC is commonly seen in association with cranial lesions. However, they do present rarely as isolated spinal lesions. Spinal NCC may present with vague symptoms, pain, paraparesis or, sometimes as, cauda equina syndrome. Spinal NCC with neurological deficits is an emergency, and it should be operated immediately followed by antiparasitic medications. We report a primary lumbar NCC patient, who presented with radicular pain. She underwent complete excision of cyst.


 

Keywords

lumbar IDEM - spinal neurocysticercosis - lumbar cyst

Introduction

Neurocysticercosis (NCC) is the most common parasitic infliction of the central nervous system (CNS), which is caused by pork tapeworm Tenia solium.[1] The term primary spinal cysticercosis (PSC) indicates isolated involvement of spine and spinal parameningeal structures without coexisting brain inclusion. PSC accounts for 1 to 3% of overall NCC.[2] Thoracic spine is the most commonly involved region in PSC, with lumbar and cervical being rarely reported. Clinical presentation for lumbar PSC is highly variable and can present with focal axial back pain or with spectrum of lower limb weakness, ranging from paresis to catastrophic cauda equine syndrome.[3] In this case report, we share our experience on rare PSC, and one of the few reports where preoperative diagnosis of NCC was suspected based on MRI 3D constructive interference in steady state (CISS) imaging.


 

Case Report

A 21-year-old female presented with insidious onset and gradual progressive pain in right gluteal region, radiating to posterior aspect to thigh and leg since 1 month, with difficulty experienced in walking due to pain. Initially, the patient was managed conservatively, after which her pain decreased in intensity, and she was able to walk after few days. When she developed radiating pain again, she presented to our outpatient department and we examined her, and there were no motor or sensory deficits. We planned MRI of lumbosacral (LS) spine.

Sagittal and coronal images of MRI LS spine with 3D CISS were suggestive of well-defined thin-walled cystic lesion in spinal canal at L3-L4 level, measuring 38 × 9 × 10 mm with nodular soft-tissue component seen in posteroinferior aspect of cystic lesion, measuring 4 × 4 × 3 mm ([Fig. 1]). Based on imaging findings, a preoperative diagnosis of lumbar intradural extramedullary (IDEM) parasitic cyst (NCC) was made. No evidence of NCC was found in MRI of brain. USG abdomen and X-ray chest were unremarkable.

Zoom
Fig. 1 (A,B) T2 sagittal sections showing hyperintense thin-walled cystic lesion at L3−4 level, located posteriorly within the dura and displacing the cord structures anteriorly. (C-E) T2 constructive interference in steady state (CISS) sagittal images showing a cystic lesion with a small mural nodule posteroinferiorly (red arrow). (F) Gross image of neurocysticercosis (NCC). (G) Histopathology section of cystic wall s/o NCC.

L3-4 laminectomy was done, with patient under general anesthesia and in prone position. No evidence of extradural lesion. Upon incising dura, gray white flap-like, thin-walled cystic lesion was noted at L3 and L4 vertebral levels, which popped out with pulsations and removed whole as a single piece. In view of NCC, copious irrigation of cavity was done with 3% saline. Watertight dural closure was done, and the wound was closed in layers.

Gross specimen was cystic in nature, grayish in color, and of size 4 × 2 × 2 cm ([Fig. 1]). Microscopic examination of sections showed cyst wall that was undulating, with three distinct layers: outer cuticular, middle cellular, and inner fibrillary layer, which is suggestive of parasitic cyst, favoring cysticercosis ([Fig. 1]).

Perioperative and postoperative periods were uneventful. The patient was treated with tablet albendazole for 28 days along with steroids for a week. She was ambulated on postoperative day 2. By postoperative day 4, she was completely relieved of pain and discharged. The patient was followed-up after 6 weeks of surgery without any complaints/complications.


 

Discussion

PSC is a rare entity which accounts for approximately 1 to 3% of all recorded NCC cases.[4] NCC of spine presents either extradural or intradural forms. Intradural is further subclassified into intradural extramedullary/subarachnoid and intramedullary form. Subarachnoid form is more common than intramedullary. Extradural lesion may be only extradural lesion, osseous lesion, or combined. NCC presents with either univesicular or multivesicular form, and the former is more common. Intramedullary NCC occurs through hematogenous spread, whereas the subarachnoid form by direct cerebrospinal fluid (CSF) dissemination.[5] Previously reported lumbar PSC in literature are mentioned in [Table 1].

Table 1

Literature on primary lumbar neurocysticercosis

Author

Age/sex

Symptom/sign

Preoperative diagnosis

Lesion level

Paterakis et al1

60/M

Left foot drop

Hydatid cyst

L5-S1

Jang et al2

50/M

B/L leg pain

Cysticercosis

L4-S1

Jongwuties et al7

59/F

Urinary retention

Arachnoid cyst

L1-L4

Park et al9

72/M

Left leg pain

Tumor/Tuberculoma

L4-S1

Yoo et al11

42/M

Back pain

Arachnoid cyst

T11-S1

Ganesan et al3

32/M

Cauda equina

Subarachnoid cyst/ Hydatid cyst

L2-S1

Zhang et al

59/F

B/L LL pain

Not described

L1/2-S1

Han et al12

59/M

Left leg pain

Not described

L1-L5

Bansal et al13

40/M

Low back ache

Tarvlov cyst

L5-S1

Sharma et al14

48/F

Low back ache

Adhesive arachnoiditis/epidermoid

L2-S2

Neurologic manifestations mainly depend upon number of cysts, location, size, stage of cysticercus larvae, severity of disease activity, and host immune response. Clinical presentation of PSC may be nonspecific and varied, with symptoms ranging from vague pain, parasthesias, and weakness of limbs to cauda equine syndrome.[6]

Main differential diagnosis of IDEM spinal cystic lesion is arachnoid cyst; others include hydatid cyst, dermoid tumors, and spinal subarachnoid cystic tumors.[7] To differentiate it from the arachnoid cyst, PSC cyst wall is enhanced in postgadolinium T1 contrast images. The 3D-CISS/fast imaging employing steady-state acquisition (FIESTA) sequence of MR imaging well demarcates cyst from surrounding. Cysts with mural nodule are better visualized in 3D-CISS sequence, which confirms the preoperative diagnosis of spinal NCC.[8] [9]

Management of spinal NCC includes both surgical and medical. Urgent surgical decompression should be performed when patient presents with neurological deficits/pain. Care should be taken not to puncture the cyst wall and contaminate the surgical field. Spillage of contents leads to recurrence. Once removed, then copious irrigation of operative area should be performed with either 3% saline or diluted povidone-iodine solution, which acts as larvicidal agent. Medical management includes albendazole, praziquantel, and steroids. Albendazole has better CNS penetration. Steroids are given to reduce inflammatory reactions. Steroids increase the levels of albendazole when coadministered, but levels of praziquantel are diminished.[10]


 

Conclusion

In an endemic country like India, any spinal intradural mass lesion NCC should undergo differential diagnosis, and to confirm it preoperatively, we suggest 3D-CISS sequence of MR imaging along with T1 postgadolinium contrast images as a diagnostic tool.


 

 

Conflict of Interest

None declared.


Address for correspondence

Krishna Kumar G., MCh
Department of Neurosurgery
Yashoda Hospital, Alexander Road, Shivaji Nagar, Secundrabad 500003, Telangana
India   

Publikationsverlauf

Artikel online veröffentlicht:
25. Mai 2021

© 2021. Neurological Surgeons’ Society of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India


  Lizenzen und Reprints
Zoom
Fig. 1 (A,B) T2 sagittal sections showing hyperintense thin-walled cystic lesion at L3−4 level, located posteriorly within the dura and displacing the cord structures anteriorly. (C-E) T2 constructive interference in steady state (CISS) sagittal images showing a cystic lesion with a small mural nodule posteroinferiorly (red arrow). (F) Gross image of neurocysticercosis (NCC). (G) Histopathology section of cystic wall s/o NCC.