The differential diagnosis for ring enhancing cerebral lesions includes:
• Cerebral abscess
• subacute infarct / hemorrhage /contusion
• radiation necrosis
• postoperative change
A helpful mnemonic is MAGIC DR
Most common parasitic disease of the nervous system. Cysticercosis is caused by Taenia solium, the pork tapeworm. Endemic in Central and South America, southern Africa, and Asia.
CT remains the best screening Neuroimaging procedure for patients with suspected Neurocysticercosis, and MRI is the imaging modality of choice.
TABLE 1. Diagnostic criteria for Neurocysticercosisa
Histologic demonstration of the parasite from biopsy of a brain or spinal cord lesion
Cystic lesions showing the scolex on CT or MRI
Direct visualization of subretinal parasites by fundoscopic examination
Lesions highly suggestive of neurocysticercosis on neuroimaging studies
Positive serum immunoblot for the detection of anticysticercal antibodies
Resolution of intracranial cystic lesions after therapy with albendazole or praziquantel
Spontaneous resolution of small single enhancing lesions
Lesions compatible with neurocysticercosis on neuroimaging studies
Clinical manifestations suggestive of neurocysticercosis
Positive CSF ELISA for detection of anticysticercal antibodies or cysticercal antigens
Cysticercosis outside the central nervous system
Evidence of a household contact with T. solium infection
Individuals coming from or living in an area where cysticercosis is endemic
History of frequent travel to disease-endemic areas
a CSF, cerebrospinal fluid; ELISA, enzyme-linked immunosorbent assay.
Anti parasitic therapy:
Albendazole vs Praziquantel.
Praziquantel is used in doses of 50 mg/kg/d for 15 days, but recommended dosages have ranged from 10 to 100 mg/kg for 3 to 21 days.
Albendazole is administered at doses of 15 mg/kg/d for 1 week.
Albendazole showed the clinical benefit of decreased seizures and enhanced resolution of cysts after treatment. Has better penetrance in the CSF and hence destroys subarachnoid and ventricular cysts.
Patients with single enhancing lesions may not need specific therapy as most of these lesions disappear spontaneously.
Simultaneous administration of corticosteroids and cysticidal drugs ameliorate the secondary effects of headache and vomiting that may occur during cysticidal drug therapy.
Anti epileptic therapy:
Single antiepileptic drug results in seizure control in most patients with epilepsy due to NCC.
Ventricular shunt placement has a role in the management of patients with obstructive hydrocephalus. Removal of intraventricular cysts is helpful.
1. Life cycle of Taenia solium
2. Axial magnetic resonance imaging scan of the brain of a different patient with neurocysticercosis showing a vesicular cyst (arrow). The head of the larva in the cyst gives the lesion a pathognomonic "hole-with-dot" appearance.
3. Brain MRI Scans: (A) T1-weighted image, showing the left sylvian fissure containing multiple thin-walled large racemose cysts along with many parenchymal cysts. The lesions are hypointense; (B) T2-weighted image showing hyperintensity of the cyst fluid at the left sylvian fissure and multiple parenchymal cysts, some with perifocal oedema; (C) proton density MRI showing right posterior horn of lateral ventricle containing an intraventricular cyst.
4. Computerized tomography showing a typical fourth ventricle Cysticercus cyst delineated by the positive contrast-medium technique.