Emergency neuroendoscopic management of third ventricular neurocysticercosis cyst presented with bruns syndrome : report of two cases and review of literature

Abstract

Neurocysticercosis is the commonest parasitic disease of the human central nervous system. The incidence of intra ventricular form of neurocysticercosis (NCC) is less common accounting 10-20% that of total central nerve system cysticercosis. Intra ventricular NCC is complicated due, to its high incidence of acute hydrocephalus caused by ball valve mechanism. The only reliable tool for diagnosis of NCC is by neuroimaging with CT or MRI. MRI preferred over CT because of its high specificity and sensitivity. In emergency situations like acute hydrocephalus one can proceed with emergency endoscopic surgery. Through the endoscopic view, intra ventricular NCC (IVNCC) has distinguished morphological features like the full moon sign. This feature not only helps in identification of IVNCC, but also guides in further endoscopic treatment strategy. Authors report two cases of 3rd ventricular NCC with acute hydrocephalus managed with emergency endoscopy. Authors have discussed the clinical features, intra operative endoscopic findings and role of endoscopy in emergency surgery for NCC with acute hydrocephalus.

Keywords: Acute hydrocephalus; Bruns syndrome; Full moon sign; Intra ventricular NCC; Neurocysticercosis; Neuroendoscopy.

Fig. 1

CT scan brain images of first case (axial) showing hydrocephalus with dilated lateral and third ventricles.

Fig. 2

A : Endoscopic view of cysticercus lesion seen obstructing the foramen of Monroe with surrounding relations. B : Cysticercus lesion appearing as the "Full moon" in the endoscopic view.

Fig. 3

A : Image showing the endoscopic view of foramen Monroe and third ventricle after the cyst removal. B : Image showing the thin walled cyst containing cysticercus larva in form of a nodule inside.

Fig. 4

Haematoxylin and eosin stained low power field image showing cysticercus larva. Cyst cavity is lined by three layers : cuticle, cellular and inner loose layer. Cephalic end of the larva showing an invaginated scolex having a sucker and hooklets is identified. Caudal end of scolex larva showing duct like invaginations surrounding a coelomic cavity.

Fig. 5

Six months post operative CT scan image of the brain showing resolved hydrocephalus.

Fig. 6

Serial axial CT scan images (A) of second case showing hydrocephalus and a hyperdense nodular lesion in the third ventricle (B) (arrow).

Fig. 7

Intraoperative endoscopic image showing cysticercus lesion completely obstructing foramen of Monroe with fornix seen superiorly (full moon endoscopic sign).

Fig. 8

Image of the cysticercus lesion removed endoscopically.

Fig. 9

Three months post operative CT brain image showing resolved hydrocephalus.