Edema surrounding calcified intracranial cysticerci: clinical manifestations, natural history, and treatment

Abstract

Calcified granulomas are the most common radiological finding in neurocysticercosis (10-20% of endemic populations). A small proportion serves as foci of seizure activity, which results in large numbers of persons with epilepsy. Calcified granulomas are not all the same. Some demonstrate blood-brain barrier dysfunction (magnetic resonance imaging enhancement) most likely due to the presence of inflammation, visualizable scolices, and/or gliosis. About half the patients with a recent history of seizures, positive serology, and only calcified lesions develop perilesional edema at the time of a seizure recurrence. The natural history, treatment, and pathophysiology of this phenomenon are not well studied. Episodes are usually associated with seizures or other neurological manifestations, resolve by 4-6 weeks, sometimes occur repeatedly, and usually involve a subset of the same calcifications. Treatment is supportive. Histopathological examination of one calcification associated with multiple perilesional edema episodes revealed significant inflammation and supports the concept that perilesional edema is inflammatory in nature. This most likely is due to host responses to released or newly recognized parasite antigen and/or upregulation of the host immune response. Immunosuppressive and anti-inflammatory agents may be useful in prevention and/or treatment of this phenomenon.

Figure 1

A joining fast attenuated fluid inversion post-gadolinium injection images of a patient who presented with seizures associated with perilesional edema around a calcification in the left frontal lobe. Repeated episodes involving the same and other calcifications have been documented. The right image demonstrates an enhancing calcification with some edema, which is better visualized in the left image.