Cysticercus cellu the metacestode stage of We estiimately 50000 - PDF document

Cysticercus cellu-, the metacestode stage of . We esti-imately 50,000 deaths annually. Emigration of infected Abbreviations used in this paper:CNS = central nervous system;CSF = cerebrospinal fluid; CT = computerized tomography; MR =magnetic resonance; NCC = neurocysticercosis. 8QDXWKHQWLFDWHG_'RZQORDGHG$087& Interestingly, the parasitic involvement of the spinal(parenchymal), the former being the most prevalent typethe spinal cord is the principal site of damage, intramed-Intramedullary spinal cord cysticerci, however, areradiological features may be similar to intra- or extramed-Neurología y Neurociruría de México; they assessed clin-both sexes are affected equally; 26% of their patients wereasymptomatic and the diagnosis was made only after per-48.2%, and hydrocephalus (29.5%). Moreover, parenchy-neurosurgical aspects in approximately 1000 cases ofbrain parenchyma in approximately 60%, in the subarach-spinal NCC. A brief review of the literature, pathophys-iology, and therapeutic and/or surgical strategies is dis-cussed. We also propose a prophylactic approach of rou-tine priorities as an attempt to eradicate parasitosis.CLINICAL MATERIAL AND METHODSwelve (7.4%) of 163 patients with NCC-related com-plications who underwent neurosurgical procedures at theDivision of Neurosurgery of the Hospital das Clínicas,between January 1980 and December 2001 were the sub-jects of this study. Spinal cysticercosis was present in allpatients. They underwent myelography, CT myelography,were included in a previous study.The diagnosis of NCC was based on clinical and epide-linked immunosorbent assay, neuroimaging, pathologicalexamination, and surgical aspects of the lesions.indicated. Laminectomy was performed in 10 patients. Pa-tients with intracranial hypertension-related hydroceph-and several patients with cysticercal meningitis also re-ceived chronic corticoisteroid therapy. In two patients inwhom no surgery was performed glucocorticoid therapyIn the evaluation of surgical or medical treatment, wesignificant improvement of the clinical neurological signs;clinical status or in patient death.RESULTSable 1 provides a summary of the clinical, surgical,and neuroimaging features found in each of the 12 patients

and neuroimaging features found in each of the 12 patients)Spinal cysticercosis of the leptomeningeal form was pre-equina was compressed. Figure 2 shows a CT myelog-cord, suggesting cysticercosis, which was confirmed dur-ing surgery. In all patients with hydrocephalus, symptoms second-7 to 48 months later (mean 27.6 ±15.5 months; median 24months). In the patient in Case 11 hydrocephalus wasabsent, but he presented with cysticercal meningitis 24or nerve damage. Most presented with symptoms corre-headache, vomiting, transient visual loss, ataxic gait, dip-lopia, and papilledema at the time hypertensive hydro-cephalus or meningitis was diagnosed. Presenting symp-weakness in eight (67%), pain in eight (67%), and sphinc-(90%) or the intradural racemose cysts (80%). Typicallythe prognosis was worse in patients with intense-to-mod-(not surgically treated), compared with those with isolatedNeurosurg. Focus / Volume 12 / June, 2002 8QDXWKHQWLFDWHG_'RZQORDGHG$087& able. The patient in Case 7 was lost to follow up. Con-sidering the other 11 patients pretreatment spinal neuro-logical deficits improved in four, were unchanged in four,Neurosurg. Focus / Volume 12 / June, 2002 Spinal cord cysticercosis: neurosurgical aspects Summary of pre- and posttreatment characteristics in 12 patients with NCC*CaseAge, (yrs)Spinalceph-Inter- PresentingNeurologicalPosttreatmentNo.SexLevelalusvalHistoryStatusTreatmentOp FindingsCourse15, FT-9yes21decreased lower-leg paraparesisT7…12 lami-intense arachnoid-progressive worsening w/limb strengthnectomyitisparaplegia & incontin-ent bladder; died of in-creased ICP2 yrs postop23, FT2…L1yes7chest/lumbar pain leg paraparesis; L1…4 lami-excised active & decreased pain; persis-radiating to lower tactile/painful nectomydegenerated sub-tence of decreased limbs & decreased hypesthesia w/ arachnoid race- muscle strength in lt leglower-limbT-3 levelmose cysts; mod-strength for 4 moserate arachnoiditis24, FL2…5noNAsudden lumbar paintactile/painful L2…5 lami-excised subarach-temporary remission of radiating to rt leghypesthesia in nectomynoid racemose pain; wide lumbar fillingfor 8 mosL3…S1 on the ltcy

sts; moderate gap (arachnoiditis) on& in L5…S1 on arachnoiditismyelography 3 yrson the rt; bilatpostop36, FT11…L5yes48difficulty walking leg paraparesis,clinicalNAslow & progressive wors-& sphincter walking w/ ening; walking w/ sup-changes for 5 mossupportport; developed neuro-40, FC5…6yes12progressive de-spastic quadri-C4…7 lami-intense arachnoid-discrete improvement of creased extremity paresis & urine nectomyitismotor deficitstrength & diffi-retention; con-culty urinating fined to bed43, Fcauda yes24lumbar pain radiat-deficit of dorsal L3…5 lami-excised racemosecomplete relief of painequinaing to rt leg flexion of rt foot;nectomycysts of cauda (L5…S1)hypalgesia on lat equina; discrete surface of leg & arachnoiditis46, FT1…2yes44progressive de-universal hypes-T1…4 lami-excised subarach-lost to follow upcreased lower- thesia w/ leg nectomy noid degenerated limb strength paraparesisracemose cystsfor several mos47, FT9…L1yes48lumbar pain radiat-leg paraparesisT12…L2 lami-excised racemose lumbar pain remained; ing to rt leg; de-nectomycysts of cauda lower-limb strength creased lower-limb equina; discrete improved; sphincter strength & sphincter arachnoiditisdisorder improved22, MC12…T1yes12lumbar pain radiat- leg paraparesisclinicalNAunchanged; died of in-ing to lower limbs creased ICP3 years& decreased lower-postop1024, Mthoraco-no24‚chest pain radiatingnormalT8…L2 lami-excised subarach- progressive worsening, lumbarto lower legsnectomynoid racemose development of para-cysts; moderatedparesis & sphincter dis-arachnoiditisorders24, ML3…4, yes36lumbar pain radiat- lt Lasègue signL4…5 lami-excised subarach-partial decreased pain; S-1ing to lt legnectomynoid racemose arachnoiditis at op level(L5…S1)cysts; moderateon CTmyelography1251, MC3…7noNAlumbar pain & low-spastic quadri-C3…7 lami-excised viable & persisting motor deficit er-limb paresthesia paresisnectomydegenerated race-& painfor 10 mos, associ- mose cysts adher-ated w/ progressiveent to cervical motor deficit thatcord; moderate started 6 mos laterarachnoiditis* ICP= intracranial pressure; NA= not applicable. Interval = interval between hydrocephalus and compression (mos). 8QDXWKHQWLFDWHG_'RZQORDGHG$087& surgical exposure of the spinal

cord, demonstrating the22.2% of the patients (nine cases), respectively.the clinical picture usually reflects states of recurrent men-be preceded by seizures months or years earlier. Hydro-cephalus may be diagnosed during an episode of meningi-tis or a few months later. Interestingly, spinal cord in-ticercosis-related meningitis. Obviously, there are excep-steroid effects on susceptibility to cysticercosis seems toInterestingly, the frequent-such as carbamazepine and phenytoin, can also alter im-and, therefore, could affect susceptibilityelaborated on the basis of topography, pathophysiology,Neurocysticercosis may also be associated with in-flammatory cerebral aneurysm and subarachnoid hemor-temporal lobe epilepsy,and stroke. Recently, a link between NCC andourpatients, during the evolution of cysticercal disease,reaches the spinal cord parenchyma or CSF. 1) One suchroute is the hemopoietic venous route, through retrogradeinto the spinal cord. Additionally, the ependymal canal iscontinuing as such in older ages in some individuals, pro-Neurosurg. Focus / Volume 12 / June, 2002 Fig. 1.Distribution of the spinal cord or nerve root lesions in Fig. 2.A CT myelography scan revealing hypodense roundedand irregular gap of filling around the spinal cord, suggesting cys- Fig. 3.Intraoperative photograph of the spinal cord demonstrat- 8QDXWKHQWLFDWHG_'RZQORDGHG$087& cord, before they transform into the 5- to 18-mm cysticer-that would explain the intramedullary form (although it isunlikely, if at all possible). 4) Lastly, although also unlike-ly, continuity from the intestinal mucosae to the intradu-ral space may allow the parasites to pass throughout sev-eral organic tissue layers, without use of the bloodstreampathway.be proportional to the tissue mass that is relative to bothit receives 15 to 20% of cardiac output. The macro- andThis fact may explain why the CNS is the organ of thement would be assisted by gravity. and carotid and vertebral circulations, the tendency of car-and some of them would then migrate throughout the fo-Alternatively, the embryos may also enter the CSF viamost commonly found in the fourth ventricle followed bythe third ventricle and then lateral ventricles. The effect ofgravit

y could without difficulty explain this fact. If thisbe documented in the spinal canal. Only in a small num-ber of the patients, however, are the cysticerci found be-(those treated surgically) did the cysticerci remain with-lower if we were to consider the entire population of pa-propose the following hypothesis to account for thelow incidence of spinal cysts: of a "sieve effect" may actare larger in size than the subarachnoid space at the cervi-embryos appears to be tro-isolation afforded by the blood-brain barrier from theAnother question is why spinal cord involvement oc-curs late in the disease course. Indeed, in nine of our 12large or racemose form of cysticercosis; or 4) immunoal-lergic or inflammatory changes occurring after the deathof the cysticercus, leading to angiitis, ischemia, and com-Similarly, hydrocephalus may be explained by the pres-noiditis causing obstruction of the ventricles outlets (iso-Additionally, hydrocephalus may also beThe treatment can be divided into two parts: first, cura-tive treatment of the patient and, second, strategic prac-Immediate control of the direct causes of the neurolog-undertaking surgery, antiinflammatory drug therapy, orAnticysticidal drugs such as albendazole or praziquan-The best treatment„surgical or medical„in patients withgiant, intraventricular, or subarachnoid forms of NCC re-Surgical treatment, with exci-sion of the cysticerci after laminectomy, is still indicatedsurgery is commonly indicated for decompression of thegenerative stage. Degenerating intramedullary cysts, how-ever, may present with adhesion to nervous tissue andThus, the use of albendazole for viable intramedullary oreven subarachnoid cysts would very probably enhance theinflammatory reaction around the cysticerci during itstreatment of symptoms (antiepileptic drugs, drugs to com-bat spasticity) and physiotherapeutic/nursing care to man-as discussed previously, corticosteroid agents may also beNeurosurg. Focus / Volume 12 / June, 2002 Spinal cord cysticercosis: neurosurgical aspects 8QDXWKHQWLFDWHG_'RZQORDGHG$087& The presence of postoperative inflammation and arach-manipulation during surg

ery. This complication is mini-Several conditions and practices are suggested in man-aging neuroparasitosis: 1) good hygienic habits and ad-and prevention of taeniasis (a] identifying and treatingcooking pork for at least 5 minutes at 65swine populations, meant to treat possible cases of taenio-sis to eliminate the source of tapeworm infection in hu-Because of its impracticality,however, it is considered more adequate to provide treat-ment to eliminate tapeworms only in those people previ-carriers. Because of this, we should make every effort toidentify individuals with the intestinal form of infection,of human intestinal infection are mandatory. An alterna-echinococcosis, paragonimiasis, trichinosis, filariasis, an-and the morbidity and mortality rates remain high despitethe use of modern neurosurgical and radiological tech-nology. The best alternative is the preventive treatment ofrelatively rare late-onset complication of NCC, usually af-fecting patients with a history of hydrocephalus. Race-mose cysticercosis and/or arachnoiditis are the predom-inant features of the disease affecting the spine. The1.Agapejev S, Da Silva MD, Ueda AK: Severe forms of NCC:2.Andrade-Mena CE, Sardo-Olmedo JA, Ramirez-Lizardo EJ:3.Andrade-Mena CE, Sardo-Olmedo JA, Ramirez-Lizardo EJ:4.Apuzzo MLJ, Dobkin WR, Zee CS, et al: Surgical considera-5.Bandres JC, White AC Jr, Samo T, et al: Extraparenchymal6.Barini O: Cisticerco macrocístico intramedular. Extirpação cir-7.Bojalil R, Terrazas LI, Govezensky T, et al: Thymus-relatedcellular immune mechanisms in sex-associated resistance to ex-8.Cabieses F, Vallenas M, Landa R: Cysticercosis of the spinal9.Canelas HM, Ricciardi-Cruz O, Escalante OAD: Cysticercosisof the nervous system: less frequent clinical forms. 10.Chimelli L, Lovalho AF, Takayanagui OM: [Neurocysticerco-11.Colli BO, Assirati Junior JA, Machado HR, et al: Cysticerco-12.Colli BO, Martelli N, Assirati JA Jr, et al: Results of surgical13.Colli BO, Martelli N, Assirati JA Jr, et al: Surgical treatment of14.Colli BO, Martelli N, Assirati Junior JA, et al: Cysticercosis ofcysticercosis: a 23 years experience in the Hospital das Clinicas15.Colli BO, Pereira CU, Assirati Junior JA, et al: Isolated fourth16.Correa D, Laclette JP, Rodriguez-del-Rosal E, et al: Hetero-17.Del Brutto

OH, Dolezal M, Castillo PR, et al: Neurocysticerco-18.Del Brutto OH, Rajshekhar V, White AC Jr, et al: Proposed19.Del Brutto OH, Sotelo J, Aguirre R, et al: Albendazole therapy20.Escobedo F: Neurosurgical aspects of neurocysticercosis, in21.Fan PC, Ma YX, Kuo CH, et al: Survival of Taenia solium cys-22.Feldmann E, Bromfield E, Navia B, et al: Hydrocephalic de-23.Flisser A, Lightowlers MW: Vaccination against Taenia solium24.Forlenza OV, Filho AH, Nobrega JP, et al: Psychiatric manifes-Neurosurg. Focus / Volume 12 / June, 2002 8QDXWKHQWLFDWHG_'RZQORDGHG$087& tations of neurocysticercosis: a study of 38 patients from a neu-25.Fragoso G, Lamoyi E, Mellor A, et al: Genetic control of sus-26.Gallani NR, Zambelli HJ, Roth-Vargas AA, et al: [Spinal cord27.Huang PP, Choudhri HF, Jallo G, et al: Inflammatory aneurysm28.Huerta L, Terrazas LI, Sciutto E, et al: Immunological medi-29.Kelley R, Duong DH, Locke GE: Characteristics of ventricular30.Leblanc R, Knowles KF, Melanson D, et al: Neurocysticercosis:31.Leite JP, Terra-Bustamante VC, Fernandes RM, et al: Calcified32.Noboa C: Albendazole therapy for giant subarachnoid cysticer-33.Parmar H, Shah J, Patwardhan V, et al: MR imaging in intra-34.Proaño JV, Madrazo I, Avelar F, et al: Medical treatment for35.Proaño JV, Madrazo I, García L, et al: Albendazole and prazi-36.Rossitti SL, Roth-Vargas AA, Moreira AR, et al: Cisticer-37.Sotelo J, Guerrero V, Rubio F: Neurocysticercosis: a new clas-38.Takayanagui OM, Jardim E: Aspectos clínicos da neurocisti-39.Takayanagui OM, Jardim E: Therapy for neurocysticercosis.40.Terrazas LI, Bojalil R, Govezensky T, et al: A role for 17-beta-41.Valença MM: Critérios diagnósticos da esquistossomose181…182,200242.Wadley JP, Shakir RA, Rice Edwards JM: Experience with neu-43.White AC Jr, Tato P, Molinari JL: Host-parasite interactions in44.Zeitz M, Schneider T, Voigtel: JMM, past and present. 45.Zlokovic BV, Apuzzo MLJ: Strategies to circumvent vascular Neurosurg. Focus / Volume 12 / June, 2002 Spinal cord cysticercosis: neurosurgical aspects 8QDXWKHQWLFDWHG_'RZQORDGHG$087&