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International Journal of Current Research and Review 

DOI: 782/IICRR.2020.121824 

Section: Healthcare 
Sci. Journal Impact 
Factor: 6.1 (2018) 
ICV: 90.90 (2018) 


BY Nc 

Radiological Findings of Spinal Neurocysticercosis 


Vasant Gawande!’, Kunal Saoji2, Ajith Nair?, Kiran Saoji‘ 

"Associate Professor, Department of Orthopedics Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi 
(Meghe), Wardha, MS, India; "Assistant Professor, Department of Orthopedics Datta Meghe Medical College, Shalinitai Meghe Hosp ital 
and Research Centre, Nagpur, MS, India; ‘Junior Res ident Department of Orthopedics Jawaharlal Nehru Medical College, Datta Meghe 
Institute of Medical Sciences, Sawangi (Meghe), Wardha, MS, India; ‘Professor, Department of Orthopedics Jawaharlal Nehru Medical 
College, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, MS, India. 


Introduction: Neurocysticercosis is one of the most common parasitic diseases of the CNS in which the central nervous system 
is involved by taenia solium. However, it is uncommon that neurocysticercosis involves the spine. 

Result: Here, we reported a 35-year-old man with intramedullary cysticercosis in the thoracic spinal cord. MRI of the spine re- 
vealed a small (0.5x0.7cm) intramedullary lesion in the cord at the level of D8 vertebral body. 

Conclusion: Since the patient had progressive neurological deficits, surgery was recommended to decompress the spinal cord. 
Here, we also conversed the diagnosis and management of intramedullary cysticercosis in the combination of the literature 


Key Words: Intramedullary, Cysticercosis, Spinal cord 


Cysticercosis is the commonest parasitic disease to affect the 
central nervous system (CNS). According to the review of 
published literature, more than 2.5 million people worldwide 
are infected. ! 

Encysted larval form of Taenia solium (Cysticerus cellulose) 
commonly called porcine tapeworm causes neurocysticer- 
cosis. The parenchyma of brain, intracranial subarachnoid 
space and ventricular system is involved when it affects the 
central nervous system. 

Intraspinal cord involvement is reported in only | to 5% of 
patients, of which leptomeningeal involvement is more com- 
mon than intramedullary involvement. 

Neurocysticercosis is one of the most common parasitic 
diseases of the CNS in which the central nervous system is 
involved by taenia solium. However, it is uncommon that 
neurocysticercosis involves the spine accounting for 1.2 % 
to 5.8 % of all cases of neurocysticercosis. 

Based on the location of cysticercus in the spine, Cysticerco- 
sis has been classified anatomically as extraspinal (vertebral) 

Corresponding Author: 

or intraspinal (epidural, subdural, arachnoid, or intramedul- 
lary), among which intramedullary type is very rare. 


A 35-year-old man presented with 3 episodes of seizures 
over 1 month. It was followed by trouble in walking associ- 
ated with falls which were followed by severe weakness in 
both lower limbs since 15 days making him confined to bed. 
His bladder and bowel habits were normal. He also com- 
plained of abnormal sensations like pins and needles in both 
lower limbs. 

On examination, his spine was normal. The patient had spas- 
ticity and power of grade 2/5 in the lower limbs, wasting of 
lower limb muscles with hypoesthesia below T7 level, and 
exaggerated deep tendon reflexes in his lower limbs. Both 
Planters were extensors. 

With these features, the patient was referred to the radiology 

MRI of the spine revealed a small (0.5x0.7 cm) 

Dr. Kunal Saoji, Assistant Professor, Department of Orthopedics, Datta Meghe Medical College, Shalinitai Meghe Hospital and Research 

Centre, Nagpur, MS, India. 
ISSN: 2231-2196 (Print) 
Received: 22.07.2020 

ISSN: 0975-5241 (Online) 
Revised: 25.08.2020 

Accepted: 5.09.2020 Published: 22.09.2020 

Bieta onan N E N E Se —————————— 1 
Int J Cur Res Rev | Vol 12 + Issue 18 » September 2020 

Gawande et al.: 

intramedullary lesion in the cord at the level of D8 vertebral 

On TIweighted image, it was isointense to CSF and on T2 it 
was slightly hypointense to CSF. Hyperintensity was noted 
in FLAIR. There was e/o a hypointensity around the lesion 
on T2 images suggestive of minimal oedema. Post-contrast 
MRI showed enhancement in the area ( Fig 1 and 2) 

MRI T2 weighted image showing a ring-like lesion 
appearing hypo intense to CSF in the intramedullary compart- 
ment of thoracic cord. 

MRI FLAIR showing a ring like lesion appearing hy- 
per intense to CSF in the intramedullary compartment of tho- 
racic cord. 

Contrast enhanced MRI shows intensely enhancing 
rim like lesion in the intramedullary compartment of thoracic 

With this presentation, possibility of an infective aetiology 
such as Tuberculoma or Neurocysticercosis was considered. 
The MRI of the brain was performed, which revealed multi- 
ple small ring enhancing lesions with hole with dot appear- 
ance in few, thus confirming diagnosis of Neurocysticercosis 

( Fig 3). 

Spinal neurocysticercosis is commonly encountered in the 
CSF spaces surrounding the cord. This site is common in spi- 
nal neurocysticercosis because of dissemination of lesions 
from brain via CSF.? 

Intramedullary NCC is an extremely rare condition. The 
probable etiology is hematogenous dissemination from a pri- 
mary source other than CNS (Fig no 1). Thoracic spine is the 
preferred site for intramedullary NCC due to higher blood 
volume in this area as compared to other spinal segments’. In 
present case also thoracic involvement in noted. 

MR imaging of intact intramedullary cysts typically shows 
cystic areas within the spinal cord along with intensity of 
cyst fluid that is analogous to CSF on both TI- and T2- (Fig 
no 2) weighted images. Sometimes the scolex can be rec- 
ognized as a mural nodule within the cavity of cyst on TI- 
weighted images. 

However it was not seen in the cord in our case but it was 
seen in the sections of brain. As in the brain, degenerating 
cysticercotic cysts within the spinal cord may show a sub- 
tle hypointense rim surrounding the intramedullary cyst on 

Gawande et al.: Radiological findings of spinal neurocysticercosis 

T2-weighted images and evidence of irregular peripheral en- 
hancement after IV gadolinium administration. Similar find- 
ing were found in present case also. 

The differential diagnosis of a small ring enhancing area in 
the cord will be tuberculoma, metastasis and abscess. The 
closest differential diagnosis is tuberculoma, however tuber- 
culoma will usually have a size of 2-8mm and appear hypo- 
or isointensity or central hyperintensity with a hypointense 
rim on T2W images and isointensity and/or hypointensity on 
T1W images (Fig no 3).* 

The other differential diagnosis includes cerebral metastasis 
and abscess. However cerebral metastasis appear isointense 
to hypointense on T1 W images and typically hyperintense on 
T2W images. The enhancement pattern in it can be uniform, 
punctate, or ring-enhancing, but it is usually intense.° 

Abscess appears hypointense on TIW images and hyperin- 
tense on T2, but there is surrounding vasogenic edema, on 
T2W images it appears as surrounding hyperintensity. With 

iv contrast abscess shows typical rim like enhancing pattern. 

The CSF examination frequently shows raised proteins, 
a low or normal glucose level, moderate level of lympho- 
cytic pleocytosis and eosinophilia. ELISA or serum enzyme- 
linked immunoelectric transfer bolt assay helps in finding 
cysticercal antibodies in CSF and have good sensitivity and 
specificity in cysticercosis diagnosis. ’ 

Timely diagnosis and management can increase the result. 
Sharma reported that 60% patients acquired improvement 
after surgery, 25% did not improve, and 15% died’. In recent 
years studies, there is significant increase in results by surgi- 
cal management; there is no death and most of patients may 
possibly live devoid of special support. When in doubt surgi- 
cal management 1s the management of choice or else medical 
therapy has its benefits. 8° 

Albendazole is a drug which is effective since 1996 in pa- 
tients with intramedullary cysticercosis. It is thought that 
preoperative adjunctive treatment with albendazole helps to 
stabilize the lesion and thus causes a strong dissection plane 
during surgery. Albendazole is generally used postsurgery as 

a routine therapy (15mg/kg/day) for 4 to 6 weeks, according 
to the idea that cysticercosis 1s a generalized disease with fo- 
cal manifestation. Moreover, Albendazole is often combined 
with corticosteroids, for the reason that its level in the blood 
can increase by the latter. ”'° 


To conclude we suggest that neurocysticercosis should be 
considered in the differential diagnosis of ring lesions in- 
volving the cord, particularly in endemic areas. 


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Int J Cur Res Rev | Vol 12 « Issue 18 - September 2020