Comparative study of CT and MRI in patients with seizures and a solitary cerebral cysticercus granuloma

We hypothesized that when contrast-enhanced CT reveals a solitary cerebral cysticercus granuloma, MRI would not usually provide additional information that might assist in management. We retrospectively compared visualisation of solitary cysticercus granulomas on contrast-enhanced CT and MRI in 16 patients presenting with seizures; gadolinium (Gd) enhancement was used in 6 patients. The granuloma was delineated well on both CT and MRI in 15 patients; in one patient, in whom CT was performed with 10-mm slices, it was seen only on contrast-enhanced MRI, CT and unenhanced MRI revealing only the surrounding oedema. On CT the granuloma was seen best on thin (2–5 mm) contrast-enhanced sections (in 10 patients). On MRI, Gd-enhanced images showed the granuloma best, as a ring-enhancing lesion, in all 6 patients. In the other 10 patients, the granuloma was seen only on T2-weighted images in 8 and on both T1- and T2-weighted images in 2. On T2-weighted images a characteristic low-signal ring with a high-signal centre was seen in 12 patients. Sensitivity of the imaging techniques was: contrast-enhanced CT (5 and 10 mm slices) 93.8% (15/16); thin (2–5 mm) section contrast-enhanced CT 100% (10/10); Gd-enhanced MRI 100% (6/6); unenhanced MRI 93.8% (15/16). MRI did not reveal additional granulomas or cysts in any patient. In patients strongly suspected to be harbouring this lesion, when 10-mm contrast-enhanced CT reveals only oedema, thin (2–5 mm) slice CT is a cost-effective alternative to MRI.     

Prevalence, incidence, and etiology of epilepsies in rural Honduras: the Salamá Study

PURPOSE: Determination of epilepsy etiology in population-based studies is difficult because of the high cost of diagnostic tests. However, cost-effectiveness may be proven if preventive public-health strategies can be established from the test results. We report an epilepsy population-based study using clinical and laboratory techniques. METHODS: A medical team administered an epilepsy survey to 88% of the residents by census in the rural county of Salamá, Honduras. Ninety of 100 participants identified with active epilepsy underwent a neurologic examination, video-electroencephalography (video-EEG), brain computed tomography (CT) scan, and serum enzyme-linked immunoelectrotransfer blot (EITB) for cysticercosis. Final diagnoses were based on the International League Against Epilepsy classifications for seizures and epilepsy syndromes. Combined epidemiologic, clinical, video-EEG, neuroimaging, and serum EITB assays were used for the diagnosis of epilepsy etiologies. RESULTS: Among 6,473 residents surveyed, 151 persons with epilepsy (prevalence rate, 23.3/1,000) were identified, 100 of whom had active epilepsy (15.4/1,000) on the prevalence day. Incidence was determined to be 92.7/100,000. Partial seizures with or without secondary generalization were common (92.2%). Symptomatic epilepsy (62%) was primarily due to neurocysticercosis (37%), perinatal brain damage (8%), post-traumatic (3%), and poststroke (2%). Eight percent were idiopathic, and 30% were cryptogenic (unknown cause). CONCLUSIONS: Symptomatic epilepsies primarily explained the high prevalence and incidence of epilepsy in Salamá. Integration of video-EEG and brain CT scan with clinical-epidemiologic evaluation was critical for determination of epilepsy etiology. Establishment of specific programs for continuation of epidemiologic surveillance, education, intervention, and long-term follow-up will benefit the Salamá region.     

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.     

Neurocysticercosisnew millennium,ancient disease and unending debate

A spurt of cases of Neurocysticercosis (NCC) at our department reopened the debate on whether to treat or not and spurred us on to review the available literature for a viable solution. Despite the disease having been around for centuries a cogent treatment plan eludes us even as other ancient scourges have been successfully engaged. Neurocysticercosis presents a peculiar problem as it is an end-stage infection, accidental in man, with a benign natural course and would have merited considerably less attention, had it not chosen to infest the brain. These unique and characteristic features are the fundamental reasons why so many different treatment strategies are continuously proffered; many or none seem to work, depending on the viewpoint. And the target organs of this otherwise unglamorous tapeworm cystthe brain, eye and spinal cord-ensure that there is always pressure, and temptation to treat rather than let it be, even if the weight of evidence is to the contrary. An overview of the history of the disease and the most recent happenings is presented here, in which these issues are reviewed with special attention to the debate on treatment. From the facts that emerge, an attempt has been made to present a workable plan that would help practicing pediatricians in treating most encountered cases till such time we hear the last word on the issue. [Indian J Pediatr 2003; 70 (4) : 337-342]     

Sub acute and chronic meningitis in children—An immunological study of cerebrospinal fluid

Cerebrospinal fluid (CSF) from 274 cases of subacute to ohronic meningitis in age groups from 3 months to 12 years were analysed for the presence of antibody response to mycobacterial and cysticercal antigens by enzyme linked immunosorbent assay (ELI8A). Simultaneously other correlative parameters such as CSF cell cytology by cytospin studies, mycobacterial antigens of Lipoarabinomannan (LAM) type (a polysaccharide antigen) by reverse passive haemagglutination assay (RPHA) CSF C-reactive protein (CRP) by latex agglutination and microbial cultures for mycobacterium tuberculosis and fungi were carried out Antimycobacterial antibody was present in 35.4% of the cases. In 57.66% of the oases there was no demonstrable immune response to either mycobacterial or cysticercal antigens. However, it was interesting to note that 5.47% of the cases revealed the presence of anticysticercal antibody in the CSF. The mycobacterial antigen (LAM poiysaccharide antigen) was found in 72.6% of the cases. There was no evidence of carcinomatous or cryptococcal meningitis. This study stresses the role of multimodal diagnostic tests on CSF for investigating cases of chronic and subacute meningitis irrespective of leading dues such as tuberculosis.     

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.     

Neuron-specific enolase in patients with neurocysticercosis

BACKGROUND: Neurocysticercosis (NC) is the most frequent parasitic disease of the human nervous system. Its clinical manifestations are varied and depend on the number and location of cysts, as well as the host immune response. Symptoms in NC usually occur when cysts enter into a degenerative phase associated with perilesional inflammation. We speculate that neuron-specific enolase (NSE)--a marker of neuronal injury--could be elevated in patients with degenerating cysts comparing to those with viable cysts. METHODS: We examined serum NSE (sNSE) and cerebrospinal fluid (CSF) NSE (cNSE) levels in 25 patients with NC: 14 patients with degenerative cysts (D), 8 patients with viable cysts (V) and 3 patients with inactive cysts. Samples of eight normal controls (C) were also obtained. Determination of albumin was performed in serum and CSF samples, and the CSF/serum albumin ratio (albumin quotient, Q(alb)) was used to estimate the blood-brain barrier permeability. RESULTS: All patients, with the exception of one case, had five or less cysts. Comparisons between V, D and C groups did not demonstrate significant differences of cNSE, Q(alb) and sNSE levels. Further, there were no significant differences of cNSE and sNSE levels between patients with or without intracranial hypertension (ICH). CONCLUSIONS: These findings suggest that the inflammatory response associated with a relatively small number of degenerating cysts does not provoke significant neuronal damage. Further studies considering patients with a larger number of cysts will be required to assess if there is evidence of neuronal damage in such more severe cases.     

Childhood epilepsy due to neurocysticercosis: a comparative study

PURPOSE: To assess the clinical profile of pediatric patients with epilepsy and neurocysticercosis (NC), and compare them with a group of pediatric patients with benign partial epilepsy to determine clinical differences, response to treatment, and prognosis. METHODS: We studied 28 patients (16 girls) with probable or definitive diagnosis of NC and epilepsy and 32 patients (16 girls) with partial benign epilepsy (BE). All patients had normal neurologic examination. We compared NC and BE patients looking for differences in demographics (age at first seizure, gender, family history); clinical presentation (type, frequency, duration, and total number of seizures, duration of epilepsy, status epilepticus, cluster, and postictal deficit); treatment [duration, number of antiepileptic drugs (AEDs), maximal dose, drug association, number of seizure-free patients, time to obtain control and recurrence after medication discontinuation]; complementary examinations (the first and the last EEG). RESULTS: The mean follow-up was 5.4 years for the 28 NC patients and 4.6 years for the 32 BE patients (p=0.98). We did not find statistical differences between NC and BE in gender, family history, types of seizures, frequency and length of seizures, previous status epilepticus, seizure clustering, and presence of postictal deficits. However, we found that NC compared with BE patients had significant longer AED treatment, more seizures after AED introduction, tried more AEDs and at maximal dose, and in 20%, required polytherapy. The recurrence rate in NC was 54.4% and this was not significantly associated with number of lesions and disease activity seen on CT scans or the presence of EEG abnormalities. CONCLUSIONS: NC presents with a mild form of epilepsy in terms of seizure severity; however, it is more challenging in regard to drug management and has a less favorable long-term prognosis in terms of seizure remission. The number of lesions or disease activity seen on computed tomography (CT) as well as EEG abnormalities have no prognostic value in childhood epilepsy due to NC.     

脑囊虫病患者免疫反应中一氧化氮作用的研究

目的 检测脑囊虫病、病毒性脑膜脑炎及非神经系统疾病患者脑脊液内一氧化氮（NO）含量变化,探讨NO参与人体对脑囊虫的免疫作用。方法 采用显色剂法检测实验组和对照组脑脊液NO含量,同时检测一般生化指标和细胞学指标。结果 脑囊虫病组脑脊液NO含量高于非神经系统疾病患者组,与病毒性脑膜脑炎患者无差异。结论 NO参与人体对囊虫的免疫过程,其作用长期存在,并可能通过某些作用影响中枢神经正常功能。