Transcript Neurocystirocercosis

Neurocysticercosis
Hiroyuki Kato
Medical Student
University of Tokyo
Case presentation
29F, immigrant from Guatamala (2001)
1 week history of bifrontal H/A, 2-3 days of N/V,
dizziness, 1 brief episode of syncope, denies any
head trauma, any seizure.
PMH: None
Medications: None
Allergies: NKDA
FH: No seizure, No TB
SH: Denies Tobacco, Alcohol and Drugs
Present status: No papilledema, no neck stiffness,
everything intact except H/A N/V
CT
CT
– cystic
expansile
lesion in the
4th ventricle
causing
obstructive
hydrocephalus
– cystic lesion in
the left gyrus
rectus
– 1.3cm
hyperdense
rim-enhancing
lesion in the
right frontal
lobe
– hyperdense
lesion in the
left caudate
No evidence of
aneurysm, stenosis,
occlusion, or AVM
MRI
– confirmed CT findings
– 2.5 cm craniocaudad
x 1.6 cm AP
(4th ventricle)
– 1.6 cm craniocaudad
x 0.9 cm AP
x 1.0 cm transverse
(right frotal)
– identified possible
scolices in R inferior
frontal lobe
4th ventricle cyst (T1)
Left gyrus rectus (T2)
Left putamen (T2)
Right frontal lobe (FLAIR)
no evidence
of leptomeningeal
or dural
enhancement. No
infarction
Case presentation
Surgery
– 12/24/09 Stereotactic endoscopic 3rd ventriculostomy
– 12/26/09 Stereotactic endoscopic resection of NCC
cyst in the 4th ventricle. (suboccipital approach)
Medication
– Antiparasitic therapy
Albendazole (started after making sure that she had no
ocular invovelment)
– Steroid
Dexamethasone
Case presentation
No complication after surgery.
Discharge Condition:
– Mental Status : Clear and coherent
– Level of Consciousness : Alert and interactive
– Activity Status : Ambulatory - Independent
Discharged on 12/29/09.
Today’s Outline
Question
– 1 Best antiparasitic drug
Albendazole or Praziquentel?
– 2 Treatment for intraventricular cyst
Medication or Resection?
What we should do in unresectable cyst?
– 3 Other surgical options
Open craniotomy
Detail in endoscope
Today’s Outline
Question
– 1 Best antiparasitic drug
Albendazole or Praziquentel?
– 2 Treatment for intraventricular cyst
Medication or Resection?
What we should do in unresectable cyst?
– 3 Other surgical options
Open craniotomy
Detail in endoscope
Is albendazole better compared to praziquentel?
PLoS Negl Trop Dis. 2008 March; 2(3): e194
Albendazol or Praziquantel ?
Meta-analysis,using 6 prospective trials
partial or total disappearance of cysts and/or control of seizures
Small number, heterogeneity, 1 was pilot trial, 3 had inadequate
sample size.
The current published data does not provide enough basis to
determine conclusively the superiority of either albendazole or
praziquantel as first-line treatment of neurocysticercosis
Garcia HH. Expert Rev Anti Infect Ther. 2008 Jun;6(3):295-8.
Antiparasitic therapy
Albedazole should be used to
– Control seizure
– Resolution
in parenchymal cysts.
However, contraindicated in Cysticercosis
encephalitis.
Next Question
Now we have discussed the antiparasitic
effectiveness in parenchymal cysts.
Then what about intraventriclar cysts?
Today’s Outline
Question
– 1 Best antiparasitic drug
Albendazole or Praziquentel?
– 2 Treatment for intraventricular cyst
Medication or Resection?
What we should do in unresectable cyst?
– 3 Other surgical options
Open craniotomy
Detail in endoscope
Treatment for intraventricular cyst
Previous studies reported that
– albendazole is effective in resolution of subarachnoid and
intraventricular cysts.
However
– Antiparasirtic therapy alone requires several months for
cyst disappearance.
– Antiparasitic treatment accelerates the inflammation
process associated with cyst degeneration and can
thereby lead to complications such as ependymitis and
arachnoiditis.
– Long term use of steroid can cause various side effects.
Am. J. Trop. Med. Hyg., 80(3), 2009, pp. 373–378
Treatment for intraventricular cyst
Surgical management is the only option for
patients presenting with acute hydrocephalus
caused by intraventricular NCC.
That’s why we did 3rd ventriculostomy to treat
obstructive hydrocephalus.
Should we resect 4th ventricular cyst?
Medication VS Resection
Retrospective, observational comparative study
Total of 140 patients with intraventricular or
subarachnoid basal cistern NCC.
Karnofsky scale improved from
–
–
a mean of 52.22 and 52.44 at the beginning
to 85.48 and 90.37 at 6 months (p < 0.003), in the
traditional treatment and MIFNES series,
respectively.
Traditional treatment
minimal invasive
flexible
neuroendoscopy
surgery (MIFNES)
treatment
antiparasitic drug
+VPshunt (if needed)
cyst resection
+ 3rd ventriculostomy(54),
no antiparasitic drug
patient
83patients
57patients
58 had previous VP shunt
21 had previous
VPshunt
all of them remained with
VPshunt even after the
treatment
only 6 of them
remained VP shunt
(15 were removed
after cyst resection)
VPshunt
5 had revision, 2 had new
Vpshunt
Childs Nerv Syst (2009) 25:1467–1475
Endoscope
Requires high technique.
May not be available in endemic
developing countries.
Difficult and hazardous in patients with
ependymitis and dense adhesions.
May cause intraventricular bleeding.
Antiparasitic drug shouldn’t be used before
resection.
J Neurosurgery Pediatrics 1 : 35-39, 2008
What we should do in unresectable
cysts?
VP shunt + antiparasitic drug use
Childs Nerv Syst (2009) 25:1467–1475
VP shunt + antiparasitic
Retrospective study
Cases in active cysts
VP shunt + antiparasitic ;
average shunt life of 38.6 weeks,
before failure
VP shunt only ;
average shunt life of 8 weeks,
shunt failures in less than 6 months,
before failure
– 33% of the patients with treatment,
– 90% of the patients without treatment,
statistically significant (P<0.05 χ2 test).
Neurosurgery. 2002 Apr;50(4):757-61; discussion 761-2.
Today’s Outline
Question
– 1 Best antiparasitic drug
Albendazole or Praziquentel?
– 2 Treatment for intraventricular cyst
Medication or Resection?
What we should do in unresectable cyst?
– 3 Other surgical options
Open craniotomy
Detail in endoscope
Comparison of surgical option
Open craniotomy for intraventricular NCC
– 3 out of 7 cases required subsequent VP shunt
Endoscopic removal for intraventricular NCC
– None of 5 cases required subsequent VP shunt
Am J Trop Med Hyg. 2009 Mar;80(3):373-8.
Transventricular, transaqueductal
“scope-in-scope” endoscopic
technique to remove a cyst in 4th
ventricle
J Neurosurgery Pediatrics 1 : 35-39, 2008
Conclusion
For parenchymal cyst
– Use albendazole with steroid
For intraventricular cyst
– Endoscopic resection
– 3rd ventriculostomy
Unresectable intraventricular cyst
– VP shunt + albendazole
Surgical treatment of cerebral cysticercosis
Neurosurg. Focus / Volume 12 / June, 2002
FIN
Thank you very much for giving me an
opportunity to study in BIDMC and HMS
clerkship!!
I will keep on studying hard in Japan,
And will make full use of this precious
experience for patient care in the future!!
I want to become a good neurosurgeon!!