Management of Trapped Fourth Ventricle in Patient with Cerebral and Spinal Neurocysticercosis

摘要

Neurocysticercosis (NCC) is the most common parasitic infection of the CNS. Surgical intervention is often required to treat for hydrocephalus with neuroendoscopy emerging as a logical alternative to craniotomies. While cranial NCC cases have increased in the United States, spinal NCC incidences have remained relatively low. We report a case of trapped fourth ventricle and myelopathy from both concomitant cranial and spinal NCC. This patient exhibited a subacute thoracic myelopathy and acute deterioration from a trapped fourth ventricle (TFV) from aqueductal and fourth ventricular outflow occlusion. She underwent urgent posterior fossa exploration. A fourth ventricular lesion consistent with NCC was removed from the distal aqueduct and the aqueduct was opened via aqueductoplasty with a ventricular catheter and balloon dilatation. She improved following surgery without extraoccular dysfunction. Intraoperative visualization and postoperative MRI flow-studies confirmed patency of the aqueduct and there was complete resolution of her fourth ventricle dilatation. With antiparasitic and corticosteroid therapy, her myelopathy has slowly improved over 9 months of follow-up. Abbreviations CSF: cerebrospinal fluidCT: computed tomographyMRI: magnetic resonance imagingNCC: neurocysticercosisTFV: trapped fourth ventricle Introduction Paranoli first described cysticercosis in the central nervous system (CNS) in 1550, but Taenia solium was not recognized as the cause until the late 19 th century by Leuckart and Küchenmeister. 46 Cysticercosis is the most common parasitic CNS infection in the world. 1,24-26,40 Endemic in Mexico, Latin America, tropical Africa, India, and Southeast Asia, neurocysticercosis (NCC) has recently begun to become more prevalent in the southwestern United States.2,41,44,46,54,59,62 Approximately one-third of the world population lives in an area where T. solium is endemic, causing 50 million infections and 50,000 deaths annually. 13 The disease begins first with taeniasis, which arises from the human ingestion of undercooked pork containing cysticercal larvae that then develop into the adult worm in the human small intestine. Eggs are excreted into human stool and ingested by pigs or humans. Cysticercosis is the stage in which the eggs hatch and the larvae penetrate the intestinal mucosa to enter the bloodstream and migrate to muscle, brain, or eyes.31,44,46,52 NCC disseminates through the CNS via small capillaries to enter the parenchyma or via the choroid plexus to enter the ventricles and subarachnoid space. Approximately 60 to 92% of NCC patients have brain parenchymal involvement, while up to 20% of patients have intraventricular NCC.2,16,28,34,35,37,38,41 The disease is often self-limited unless symptomatic hydrocephalus develops, necessitating surgical intervention. 2,9,30,44,46,49,57,59 NCC may also result in epileptic seizures, meningitis, intracranial hypertension, and focal neurological deficits. 13 In endemic regions, NCC is the most common cause of seizures and hydrocephalus. 18,41 Spinal NCC often presents with myelopathy and progressive weakness from compression of the spinal cord or cauda equina. 32 We report a case of TFV and myelopathy from NCC. This patient exhibited a subacute thoracic myelopathy and acute deterioration from a TFV from aqueductal occlusion. She underwent urgent posterior fossa exploration. A lesion consistent with NCC was removed from the distal aqueduct and the aqueduct was opened via aqueductoplasty with a ventricular catheter and balloon dilatation. She improved following surgery without extraoccular dysfunction. Intraoperative visualization and postoperative MRI flow-studies confirmed patency of the aqueduct and there was complete resolution of her fourth ventricle dilatation. With antiparasitic and corticosteroid therapy, her myelopathy has slowly improved over 9 months of follow-up. Case Report History and Presentation: This 40-year old female initially presented to an outsi