IMAGE OF THE WEEK

Prof.Dr.P.Vijayaraghavan’s Unit

Presented by

Dr.T. Jaya Packiam

CASE SUMMARY

A 16 years old boy admitted with complaints of Abnormal movement left thumb and left eyelid more than 1 hour.

Patient takes mixed diet

General examination and systemic examination were unremarkable.

Routine investigations CBC LFT RFT ECG CXR were also normal.

T1 WEIGHTED MRI

T2 WEIGHTED MRI

MRI FLAIR

MRI CONTRAST

DIFFERENTIAL DIAGNOSIS

Infections- neurocysticercosis, tuberculomas , toxoplasmosis, cryptococcosis

histoplasmosis,candida albicansMetastasesAbscessesGranulomas Resolving hematomas Primary cns lymphomasMultiple sclerosisVascular malformationsThrombosed aneurysms

Tuberculomas NEUROCYSTICERCOSIS

1.Usually larger>2CM and usually multiple Smaller<2CM,may be single or multiple

2.Associated with basal meningitis or hydrocephalus.

NOT ASSOCIATED.

3.They are more common in posterior fossa .

Most commonly occur at the gray-white junction.

4.Look for CF of tb elsewhere lungs,lymph nodes,intestine.

Look for occular involvement,muscle involvement or subcutaneous nodules

5.T2 weighted MRI showsHypointense. scolex will be absent.Midline shift will be present.Conglomerate enhancement

T2 weighted MRI shows Hyperintense. scolex will be present.No Midline shift.Isolated ring enhancement.

6.MR spectroscopy may show lipid peaks with tuberculoma.

MR spectroscope may show multiple amino acid peaks.

MRI FINDINGS IN NEUROCYSTICERCOSIS

T1W1 T2W2 MRI FLAIR

VESICULAR-ISOINTENSE TO CSF,DISCRETE ECCENTRIC SCOLEX(HYPERINTENSE)

ISOINTENSE TO CSF.DISCRETE ECCENTRIC SCOLEX.NO EDEMA.

ISO INTENSE TO CSF. DISCRETE ECCENTRIC SCOLEX NO EDEMA

COLLOIDAL VESICULAR-CYST MILDLY HYPERINTENSE TO CSF

HYPERINTENSE TO CSF,MILD TO MARKEDEDEMA

HYPERINTENSE TO CSF,MILD TO MARKEDEDEMA

GRANULAR NODULAR-THICKENED RETRACTED CYST WALL.EDEMA DECREASES.

NODULAR CALCIFIED-DIFFICULT TO DETECT

THICKENED RETRACTED CYST WALL .EDEMA REDUCED.

SHRUNKEN CALCIFIED LESION

DISCUSSION

• Neurocysticercosis is the most common parasitic disease of CNS.

• Intraparenchymal parasitic infection caused by pork Tapeworm Tinea solium.

• 4 pathogenic stages • -Vesicular(larva alive)• -colloidal vesicular(degenerating larva)• -granular nodular(healing)• -nodular calcified.(healed)

Cut section of brain affected by NCC

GENERAL FEATURESLocation: cysterns>parenchymal>ventricles

-parenchymal cyst often hemispheric at grey white junction.

-Intraventricles often isolated

-Basal cisterns cysts may be racemose(Multiple Grapelike)

-Size of the cyst 1-2cm and scolex will be 1-4mm.

-Lesions may be different stages in same patient.

CINICAL FINDINGS

New onset seizures with or without generalisation

May involve brain parenchyma – seizure/FND

Subarachnoid space / Ventricular Space – May mimic Intraspinal tumors.

Cysticercosis can be diagnosed several ways.

• Travels • Eating • MRI or CT brain scans • Blood tests-ELISA

TREATMENT• ANTI CONVULSANT THERAPY:

CAN BE STOPPED ONCE CT SHOWS RESOLUTION OF LESION

• ANTIHELMINTHIC THERAPY:

• ALBENDAZOLE 15MG/KG/DAY IN 2DOSES FOR 8DAYS• PRAZIQUANTEL 50MG/KG/DAY TDS FOR 15 DAYS

TO REDUCE THE INFLAMMATORY RESPONSE OF DEGENERATING PARASITES.

• PREDNISOLONE/DEXAMETHASONE.

THANK YOU

Thank you..........