Epilepsy and neurocysticercosis in rural Tanzania—An imaging study

Purpose:   In developing countries, neurocysticercosis (NCC) is a common cause of epilepsy. Most of the work on NCC and epilepsy has been compiled in Latin America. To date, comprehensive neuroimaging studies are missing in sub-Saharan Africa.
Methods:   In our study, we interviewed 212 people with epilepsy (PWE) and performed cerebral computed tomography (CT) at the Haydom Lutheran Hospital in northern Tanzania. Control cerebral CT scans were selected from 198 consecutive individuals without epilepsy. Sera of PWE with lesions indicating NCC (n = 20), PWE without NCC lesions (n = 20), and healthy individuals (n = 20), as well as cerebrospinal fluid (CSF) samples of PWE with NCC lesions (n = 11) were investigated for anticysticercal antibodies.
Results:   Definite NCC lesions were present in five (2.4%), lesions highly suggestive of NCC in 24 (11.3%), and lesions compatible with NCC in nine (4.2%) PWE. This compares to two (1.0%) people with definite NCC lesions, two (1.0%) with lesions highly suggestive of, and six (2.9%) with lesions compatible with NCC in the control group. NCC lesions were significantly more frequent in PWE compared to controls (p < 0.0001). CT results, and serum and CSF analysis taken together, we diagnosed 22 (10.4%) individuals with probable and 7 (3.3%) with definitive NCC in our cohort of PWE.
Conclusion:   For the first time in sub-Saharan Africa, we give evidence within a large-scale neuroimaging study that NCC, a so far neglected infectious disease, represents a major cause of epilepsy.     

Active neurocysticercosis,parenchymal and extra parenchymal: A study of 38 patients

In this retrospective study we have analysed a series of 38 patients seen from 1983 to 1992 (mean follow-up, 4.5 years) with active neurocysticercosis (NCC), 23 (60.5%) with parenchymal and 15 (39.5%) with extraparenchymal NCC. Classification into these two forms of NCC was based on computed tomography and magnetic resonance imaging criteria. The enzyme-linked immunosorbent assay performed in cerebrospinal fluid, for anti-Taenia solium antibodies, was positive in 18 of 23 (78%) cases. Epilepsy and/or intracranial hypertension were the most common clinical presentation (92%). Twenty-three (60.5%) of 38 patients were treated with praziquantel and/or albendazole. In parenchymal NCC, the efficacy of medical therapy was complete in 13 of 16 (81%) and partial in 3 of 16 (19%) patients. In contrast, in all cases of extraparenchymal NCC treated with cysticidal drugs the results were disappointing. A ventriculoperitoneal shunt was performed in 9 of 13 patients with extraparenchymal NCC and hydrocephalus. Severe complications, including two deaths, associated with the natural evolution of the disease or with surgery, occurred only in extraparenchymal NCC. Therefore, we confirm the existence of the two forms of active NCC, parenchymal and extraparenchymal, which are strikingly different in clinical presentation, medical therapy response, complications, morbidity and mortality.     

Epilepsy and neurocysticercosis in rural Bolivia: a population-based survey

PURPOSE: To evaluate the frequency of neurocysticercosis (NCC) in a well-defined prevalent cohort of epilepsy patients in the rural area of the Cordillera province. METHODS: We carried out a two-phase door-to-door neuroepidemiologic survey in a sample of 10,124 subjects in a rural area of the Cordillera Province, Bolivia, to detect the prevalence of the most common neurologic disorders including epilepsy. A team of health workers administered a standard screening instrument for neurologic diseases; subjects found positive at the screening phase underwent a complete neurologic examination. Epilepsy patients were diagnosed according to the definition proposed by the International League Against Epilepsy (ILAE, 1993). Epilepsy patients identified this way underwent electroencephalographic recording, computed tomography (CT) scan, and serologic evaluation to detect antibodies against Taenia solium by enzyme-linked immunoelectrotransfer blot. RESULTS: At the end of the survey, we detected 124 defined prevalent epilepsy patients. On the basis of the classification proposed by the ILAE in 1981, partial seizures were the most common type diagnosed (66 patients, 53.3%). Of the 124 patients, 105 underwent CT scan, and a serum sample was taken to detect antibodies against T. solium in 112 patients; for 97 patients, both neuroradiologic and serologic data were available. Considering radiologic, serologic, and clinical features, of these 124 patients, 34 (27.4%) fulfilled the diagnostic criteria for definitive or probable NCC proposed in 2001. Of these 34 patients 24 (70.6%) had partial seizures. CONCLUSIONS: Our data confirm a high frequency of NCC among a well-defined prevalent cohort of epilepsy patients.     

脑囊尾蚴病神经影像学表现与循环抗原相关性研究

目的探讨脑囊虫病血清循环抗原（CAg）与神经影像学（CT、MRI）的关系。方法根据诊断脑囊虫病的四个标准,对确诊的36例脑囊虫病病人行CAg定量测定及神经影像学检查并分期。结果根据神经影像学检查,36例脑囊虫病人在活虫期、变性死亡早期、变性死亡后期及钙化期之间的CAg水平有显著性差异（P〈0.01）。相关性分析表明血清中CAg的含量与脑囊虫病的神经影像学表现具有正相关性,其相关系数为0.871。结论（1）脑囊虫病人循环抗原与神经影像学（CT、MRI）表现具有相关性;（2）血清循环抗原的检查可用于对脑囊虫病的早期诊断和指导临床治疗。     

Paradoxical migrating cyst: An unusual presentation of intraventricular neurocysticercosis with a coincidental pituitary adenoma

Intraventricular neurocysticercosis is an uncommon entity which may become symptomatic due to cerebrospinal fluid flow obstruction. Migration of intraventricular cysts through the ventricular spaces is a rare occurrence. This phenomenon is poorly understood but may be due to pressure changes within the ventricular cavities. We present a patient with intraventricular neurocysticercosis with paradoxical transaqueductal migration of the cyst from the cerebral aqueduct to the fourth ventricle shortly after ventricular drain placement for acute hydrocephalus. The patient also presented with a coincidental sellar and suprasellar mass, later pathologically proven to be a pituitary adenoma. The migration of this cyst resulted in spontaneous relief of obstruction at the cerebral aqueduct, thus restoring normal cerebrospinal fluid pathways and avoiding permanent shunting. We discuss the possible mechanisms and implications of cyst migration, and the diagnostic challenges of concomitant findings of a pituitary mass and neurocysticercosis. Although the presence of a sellar and suprasellar mass in a patient with known neurocysticercosis should raise clinical suspicion for the possibility of sellar neurocysticercosis, pituitary macroadenoma is a more common entity and a more likely etiology for a sellar lesion.     

Epilepsy and neurocysticercosis in Atahualpa: a door-to-door survey in rural coastal Ecuador

PURPOSE: To determine the prevalence of epilepsy and the role of neurocysticercosis in the occurrence of epilepsy in Atahualpa. METHODS: We used a door-to-door survey to detect subjects with epileptic seizures, to collect a blood sample for determination of anticysticercal antibodies, and to evaluate social characteristics of the population, including household pig ownership. Neurologists examined suspected cases and a sample of negative individuals. Then patients with epilepsy, as well as age- and sex-matched controls, underwent a head computed tomography (CT) and a scalp EEG. RESULTS: The questionnaire was answered by 2,415 of 2,548 residents of Atahualpa, and cysticercosis serology was performed in 1,687 consenting individuals. Cysticercosis seroprevalence was 145 (8.6%) per 1,686). Neurologic examination confirmed 24 patients with epilepsy (crude prevalence, 9.9 per 1,000 population, and 10.8 per 1,000 when adjusted to the United States population). After adjustment by age, sex, and pig raising, positive serology was strongly associated with epilepsy (odds ratio (OR), 4.16; 95% confidence interval (CI), 1.6-11.2). CT findings compatible with neurocysticercosis were found in five patients with epilepsy and also were more frequent than in controls, although this did not reach statistical significance (five of 19 vs. one of 19; p = 0.125, McNemar's test). Besides these five cases, three other patients with epilepsy had positive serology (one with a normal CT and two who did not have a CT). CONCLUSIONS: Neurocysticercosis is associated with one-third of cases of epilepsy in Atahualpa and may be a major contributory factor for the excess fraction of epilepsy seen in this population.     

大囊型脑囊虫病的诊断与治疗

目的 探讨大囊型脑囊虫病的临床特点和最佳治疗方法.方法 回顾性分析住院确诊的5例大囊型脑囊虫病的临床特点、影像学检查和治疗方法.结果 大囊型脑囊虫病颅内压增高不明显;MRI平扫及增强大囊泡寄生部位散在脑实质及小脑,囊泡呈圆形或类圆形,个别有分叶,囊壁薄而规则,大囊呈长T1长T2信号,增强扫描3例表现为囊壁呈环状轻度强化、2例无强化;2例外科手术治疗,2例吡喹酮和阿苯达唑联合治疗,1例吡喹酮治疗无效加用阿苯达唑明显见效.结论 大囊型脑囊虫病临床及影像学有特征性改变;药物治疗是根本;阿苯达唑对于大囊型脑囊虫病疗效好.     

Reduced percentage of neurocysticercosis cases among patients with late-onset epilepsy in the new millennium

Objective

To determine if the number of neurocysticercosis cases among patients with late-onset epilepsy has decreased over the past two decades.

Design

Retrospective cohort study of 431 consecutive patients with recurrent seizures starting after the age of 20 years evaluated at our Institution from 1990 to 2009.

Methods

Patients were classified according to the year in which they were first seen. Group I included 129 patients evaluated between 1990 and 1994, Group II included 108 patients evaluated between 1995 and 1999, Group III included 106 patients evaluated between 2000 and 2004, and Group IV included 88 patients evaluated between 2005 and 2009. We correlated the percentage of persons with cryptogenic and symptomatic epilepsy between the groups to determine if there was any change in the causes of late-onset epilepsy.

Results

One hundred seventy-one patients had cryptogenic and 260 had symptomatic epilepsy. Common causes of symptomatic epilepsy were neurocysticercosis in 120 cases, cerebrovascular disease in 68, and brain tumors in 40. We found a reduction in the number of patients with symptomatic epilepsy (p = 0.0007) as well as a reduction in the number of neurocysticercosis cases (p = 0.0004) over the study years. There was a reduction in the weight of neurocysticercosis as an etiological factor for symptomatic late-onset epilepsy related to a drop in the number of patients with this condition evaluated between 2005 and 2009 (p = 0.0045).

Conclusion

The number of neurocysticercosis cases among patients with late-onset epilepsy has changed over the years. This parasitic disease is no longer the most common cause of symptomatic late-onset epilepsy in our population.     

Endoscopic excision of intraventricular neurocysticercosis in children: a series of six cases and review

Objects Neurocysticercosis (NCC) affects both adults and children, but it is uncommon in childhood. The clinical presentation and management of intraventricular neurocysticercosis (IVNCC) in children has not been described adequately. We, therefore, present our series of six children with IVNCC managed by endoscopic excision. Materials and methods A retrospective analysis of six children with IVNCC was performed. The endoscopic technique practiced is described. Complete excision of the intraventricular cyst was performed in all patients. Simultaneously, five endoscopic third ventriculostomies, one septostomy, and one foramenotomy were performed. There were no perioperative and postoperative complications. Mean follow-up duration was 24.8 months. Clinical improvement was seen in all children, and none required shunting. Follow-up radiology showed no residual lesion and decreased ventricle size in all patients. Conclusion Endoscopic IVNCC cyst excision along with internal CSF diversion is a safe and effective option and avoids shunt and its related complications in these children.     

Risk of seizures and neurocysticercosis in household family contacts of children with single enhancing lesions

A small, single enhancing lesion (SEL) is often noted upon computed tomography (CT) in children and young adults with recent focal or generalized seizures. A high frequency of seizures has been reported in family members of persons with SEL. We studied the prevalence of seizures and cysticercus electro-immuno-transfer blot (EITB) based seropositivity among family members, specifically household family contacts of pediatric subjects with a SEL. An attempt was also made to determine the etiology of seizures in household family contacts using magnetic resonance imaging (MRI). Information regarding seizure semiology, personal and food habits and detailed family pedigrees was obtained from 20 consecutive pediatric subjects with a SEL and 51 of their household family contacts. EITB sero-assays and stool examinations were performed on all participating subjects. MRIs were done on all EITB positive household family contacts. A family history of seizures was obtained in six index children (30%) (five household first-degree relatives and two distant relatives). Seventeen index children (85%) and 14 family contacts (27%) were EITB positive. A tendency towards clustering of EITB positive cases within individual families was observed. Stool examinations did not reveal Taenia species ova in any of EITB positive subjects. Neuroimaging studies revealed abnormalities consistent with active or inactive neurocysticercosis in all five household family contacts with history of seizures. Four of these five subjects were EITB positive and one was EITB negative. We concluded that children with SEL and seizures may have a family history of seizures. There is a high seropositivity rate in household family contacts of pediatric subjects with solitary cysticercus granulomas (SCGs). EITB based seropositivity in household family contacts with seizures, strongly predicts a cysticercal etiology for seizures. It may be worthwhile to screen household family contacts of children with SEL for taeniasis-cysticercosis.     

A new complement fixation test for the diagnosis of neurocysticercosis in cerebrospinal fluid

Summary As a modification of the classical complement fixation test, a new test for immunodiagnosis in cerebrospinal fluid (CSF) was developed. When the assay was used for the diagnosis of neurocysticercosis in 149 CSF samples from patients and 1036 from controls, results showed 93% concordance with positives and 97% with negatives when compared with the results obtained by ELISA; in addition, it was positive in 12 of 16 cases of neurocysticercosis in which negative results had been obtained by ELISA. The new complement fixation test is particularly useful in CSF because of the immunological peculiarities of the subarachnoid space, where local synthesis of oligoclonal antibodies is induced by infectious agents. Reagents used for the assay are easy to produce and preserve, and the test is inexpensive, reliable and easy to perform. As this test detects the immunobiological consequence of the antigen-antibody reaction, it can be used in conjunction with other assays, such as ELISA, that measure the reaction directly, thus increasing the diagnostic possibilities. It may also be used where financial or technical limitations hinder access to other immunodiagnostic tests.     

Group therapy for patients with psychogenic nonepileptic seizures: a pilot study

Great advances have been made in the diagnosis of people with psychogenic nonepileptic seizures (PNES) since the advent of video/EEG monitoring. However, treatment options for this population have lagged significantly. This pilot study was undertaken to evaluate whether group therapy done with a psychodynamic focus would offer a useful intervention. Twelve patients entered the study and seven completed at least 75% of the 32 weekly sessions. The Beck Depression Inventory and the Global Severity Index of the Symptom Checklist-90 showed improvement as well as an overall decrease in PNES frequency. The data suggest that group therapy focusing on interpersonal issues may benefit patients with PNES.     

Group therapy for patients with psychogenic nonepileptic seizures: A pilot study

Great advances have been made in the diagnosis of people with psychogenic nonepileptic seizures (PNES) since the advent of video/EEG monitoring. However, treatment options for this population have lagged significantly. This pilot study was undertaken to evaluate whether group therapy done with a psychodynamic focus would offer a useful intervention. Twelve patients entered the study and seven completed at least 75% of the 32 weekly sessions. The Beck Depression Inventory and the Global Severity Index of the Symptom Checklist-90 showed improvement as well as an overall decrease in PNES frequency. The data suggest that group therapy focusing on interpersonal issues may benefit patients with PNES.     

Short course of prednisolone in Indian patients with solitary cysticercus granuloma and new-onset seizures

PURPOSE: To evaluate the role of a short course of oral corticosteroids in Indian patients with solitary cysticercus granuloma with seizures. METHODS: In this open-label, randomized, prospective follow-up study, 97 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either antiepileptic monotherapy alone (n = 48) or antiepileptic monotherapy with prednisolone (n = 49). The patients in the latter group received prednisolone, 1 mg/kg/day for 10 days, followed by tapering over next 4 days. The patients were followed up for 6 months. Repeated CT scans were performed after 1 and 6 months. RESULTS: The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 1 and 6 months demonstrated a significantly better response for prednisolone as far as complete resolution of CT lesion was concerned. Kaplan-Meier analysis suggested significantly less probability of seizure recurrence for prednisolone-treated patients. At 6 months, Kaplan-Meier estimated risk of seizure after first seizure was 2% in prednisolone-treated patients in comparison to 13% for those who were not given prednisolone. CONCLUSIONS: Short-term prednisolone therapy helps in rapid resolution of solitary cysticercus granuloma in Indian patients with new-onset seizures. Resolution of lesions is associated with improved seizure-related prognosis.     

Immunochemical detection of antigens of larval Taenia solium and anti-larval antibodies in the cerebrospinal fluid of patients with neurocysticercosis

A simple and quantitative enzyme-linked immunosorbent assay (ELISA) has been developed for the detection of antigens of larval Taenia solium in the cerebrospinal fluid (CSF) of patients with cerebral cysticercosis. Another ELISA was developed for detecting antibodies in CSF against larval antigens. The examination of sixteen patients with clinical diagnosis of cerebral cysticercosis revealed that eleven patients had both circulating larval antigens and anti-larval IgG (but not IgM) antibodies in their cerebrospinal fluids. Of these patients, those with surgically and histologically confirmed infections were all positive by the two tests. CSF samples from nine normal individuals and from six patients suffering from proven neurological disorders other than neurocysticercosis were negative for both tests. In development of these assays it was found that cross-linking of antigens to microtiter plates further improved the performance of the ELISA. The results of this study suggest that either or both of these tests may be useful in discriminating between neurocysticerosis and other clinically related diseases.     

Seizure disorder mimicking an acute confusional state as clinical presentation of neurocysticercosis: neuroimaging, EEG findings and clinical correlations

Epilepsy is the main clinical manifestation of neurocysticercosis (NC). We studied an adult subject who presented a seizure disorder mimicking an acute confusional state as clinical expression of NC. Diagnosis was made with neuroimaging and western blot determination of specific antibodies on serum. Computed tomography and magnetic resonance imaging displayed multiple calcifications and a few transitional cysts in the cerebral parenchyma. Electroencephalography showed a pattern of periodic lateralized epileptiform discharges (PLEDs) which could be related topographically to a cystic lesion located in the left parietal lobe. In our view there was a clear pathogenic correlation between the seizure disorder and the parasitic cyst located in the left parietal lobe. Neither antiepileptic drugs nor steroids were prescribed. Follow-up to one year ruled out other clinical manifestations of the disease. This case is an example of acute symptomatic seizure related to a transitional cystic lesion of NC. Received: 31 February 2001 / Accepted in revised form: 13 July 2001