Radiological Findings Of Spinal Neurocysticercosis

International Journal of Current Research and Review

DOI: http://dx.doi.org/10.31 782/IICRR.2020.121824

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Radiological Findings of Spinal Neurocysticercosis

Scopus’

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.

ABSTRACT

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

review.

Key Words: Intramedullary, Cysticercosis, Spinal cord

INTRODUCTION

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.

CASE

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
department.

Imaging
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
body.

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
cord.

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.
6

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. ”'°

CONCLUSION

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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