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Neurocysticercosis Hiroyuki Kato Medical Student University of Tokyo Case presentation 29F, immigrant from Guatamala (2001) 1 week history of bifrontal H/A, 2-3 days of N/V, dizziness, 1 brief episode of syncope, denies any head trauma, any seizure. PMH: None Medications: None Allergies: NKDA FH: No seizure, No TB SH: Denies Tobacco, Alcohol and Drugs Present status: No papilledema, no neck stiffness, everything intact except H/A N/V CT CT – cystic expansile lesion in the 4th ventricle causing obstructive hydrocephalus – cystic lesion in the left gyrus rectus – 1.3cm hyperdense rim-enhancing lesion in the right frontal lobe – hyperdense lesion in the left caudate No evidence of aneurysm, stenosis, occlusion, or AVM MRI – confirmed CT findings – 2.5 cm craniocaudad x 1.6 cm AP (4th ventricle) – 1.6 cm craniocaudad x 0.9 cm AP x 1.0 cm transverse (right frotal) – identified possible scolices in R inferior frontal lobe 4th ventricle cyst (T1) Left gyrus rectus (T2) Left putamen (T2) Right frontal lobe (FLAIR) no evidence of leptomeningeal or dural enhancement. No infarction Case presentation Surgery – 12/24/09 Stereotactic endoscopic 3rd ventriculostomy – 12/26/09 Stereotactic endoscopic resection of NCC cyst in the 4th ventricle. (suboccipital approach) Medication – Antiparasitic therapy Albendazole (started after making sure that she had no ocular invovelment) – Steroid Dexamethasone Case presentation No complication after surgery. Discharge Condition: – Mental Status : Clear and coherent – Level of Consciousness : Alert and interactive – Activity Status : Ambulatory - Independent Discharged on 12/29/09. Today’s Outline Question – 1 Best antiparasitic drug Albendazole or Praziquentel? – 2 Treatment for intraventricular cyst Medication or Resection? What we should do in unresectable cyst? – 3 Other surgical options Open craniotomy Detail in endoscope Today’s Outline Question – 1 Best antiparasitic drug Albendazole or Praziquentel? – 2 Treatment for intraventricular cyst Medication or Resection? What we should do in unresectable cyst? – 3 Other surgical options Open craniotomy Detail in endoscope Is albendazole better compared to praziquentel? PLoS Negl Trop Dis. 2008 March; 2(3): e194 Albendazol or Praziquantel ? Meta-analysis,using 6 prospective trials partial or total disappearance of cysts and/or control of seizures Small number, heterogeneity, 1 was pilot trial, 3 had inadequate sample size. The current published data does not provide enough basis to determine conclusively the superiority of either albendazole or praziquantel as first-line treatment of neurocysticercosis Garcia HH. Expert Rev Anti Infect Ther. 2008 Jun;6(3):295-8. Antiparasitic therapy Albedazole should be used to – Control seizure – Resolution in parenchymal cysts. However, contraindicated in Cysticercosis encephalitis. Next Question Now we have discussed the antiparasitic effectiveness in parenchymal cysts. Then what about intraventriclar cysts? Today’s Outline Question – 1 Best antiparasitic drug Albendazole or Praziquentel? – 2 Treatment for intraventricular cyst Medication or Resection? What we should do in unresectable cyst? – 3 Other surgical options Open craniotomy Detail in endoscope Treatment for intraventricular cyst Previous studies reported that – albendazole is effective in resolution of subarachnoid and intraventricular cysts. However – Antiparasirtic therapy alone requires several months for cyst disappearance. – Antiparasitic treatment accelerates the inflammation process associated with cyst degeneration and can thereby lead to complications such as ependymitis and arachnoiditis. – Long term use of steroid can cause various side effects. Am. J. Trop. Med. Hyg., 80(3), 2009, pp. 373–378 Treatment for intraventricular cyst Surgical management is the only option for patients presenting with acute hydrocephalus caused by intraventricular NCC. That’s why we did 3rd ventriculostomy to treat obstructive hydrocephalus. Should we resect 4th ventricular cyst? Medication VS Resection Retrospective, observational comparative study Total of 140 patients with intraventricular or subarachnoid basal cistern NCC. Karnofsky scale improved from – – a mean of 52.22 and 52.44 at the beginning to 85.48 and 90.37 at 6 months (p < 0.003), in the traditional treatment and MIFNES series, respectively. Traditional treatment minimal invasive flexible neuroendoscopy surgery (MIFNES) treatment antiparasitic drug +VPshunt (if needed) cyst resection + 3rd ventriculostomy(54), no antiparasitic drug patient 83patients 57patients 58 had previous VP shunt 21 had previous VPshunt all of them remained with VPshunt even after the treatment only 6 of them remained VP shunt (15 were removed after cyst resection) VPshunt 5 had revision, 2 had new Vpshunt Childs Nerv Syst (2009) 25:1467–1475 Endoscope Requires high technique. May not be available in endemic developing countries. Difficult and hazardous in patients with ependymitis and dense adhesions. May cause intraventricular bleeding. Antiparasitic drug shouldn’t be used before resection. J Neurosurgery Pediatrics 1 : 35-39, 2008 What we should do in unresectable cysts? VP shunt + antiparasitic drug use Childs Nerv Syst (2009) 25:1467–1475 VP shunt + antiparasitic Retrospective study Cases in active cysts VP shunt + antiparasitic ; average shunt life of 38.6 weeks, before failure VP shunt only ; average shunt life of 8 weeks, shunt failures in less than 6 months, before failure – 33% of the patients with treatment, – 90% of the patients without treatment, statistically significant (P<0.05 χ2 test). Neurosurgery. 2002 Apr;50(4):757-61; discussion 761-2. Today’s Outline Question – 1 Best antiparasitic drug Albendazole or Praziquentel? – 2 Treatment for intraventricular cyst Medication or Resection? What we should do in unresectable cyst? – 3 Other surgical options Open craniotomy Detail in endoscope Comparison of surgical option Open craniotomy for intraventricular NCC – 3 out of 7 cases required subsequent VP shunt Endoscopic removal for intraventricular NCC – None of 5 cases required subsequent VP shunt Am J Trop Med Hyg. 2009 Mar;80(3):373-8. Transventricular, transaqueductal “scope-in-scope” endoscopic technique to remove a cyst in 4th ventricle J Neurosurgery Pediatrics 1 : 35-39, 2008 Conclusion For parenchymal cyst – Use albendazole with steroid For intraventricular cyst – Endoscopic resection – 3rd ventriculostomy Unresectable intraventricular cyst – VP shunt + albendazole Surgical treatment of cerebral cysticercosis Neurosurg. Focus / Volume 12 / June, 2002 FIN Thank you very much for giving me an opportunity to study in BIDMC and HMS clerkship!! I will keep on studying hard in Japan, And will make full use of this precious experience for patient care in the future!! I want to become a good neurosurgeon!!