Migration of intraventricular neurocysticercus after ventriculostomy
A 42-year-old male patient presented with new onset seizures with two episodes of seizure over 20 days. He also complained of severe intermittent headaches for 2 weeks. There was no history of fever. The patient did not have any other significant systemic complaints. Neurologic examination did not reveal any significant abnormality. There were no focal neurologic deficits.\nRoutine blood investigations were within normal limits and there was no evidence of electrolyte imbalance. A CSF analysis revealed increased proteins (73 mg%). CSF was negative for HIV antibodies and CSF culture was sterile.\nA contrast-enhanced CT scan was performed taking 3 mm axial sections from base of skull to the vertex after injecting 30 ml if iv contrast, on a 6 slice Seimens Somatom scanner. There was dilatation of both lateral ventricles and the third ventricle with associated subependymal transudation of CSF. A subtle well-defined rounded lesion was noted within the third ventricle. The lesion was of CSF density and showed a punctate enhancing focus within. The fourth ventricle was normal []. There were no obvious neuroparenchymal lesions. The cranial vault appeared normal. A provisional diagnosis of third ventricular neurocysticercosis was made and the patient was referred for an MRI.\nMRI of the brain was performed using a 1.5T Seimens Avanto magnet with a standard head matrix coil. Standard T1 and T2- weighted images were acquired. In addition, a fluid inversion recovery (FLAIR) sequence was also obtained.\nMRI revealed dilatation of the lateral and third ventricles with subependymal transudation of fluid. A cystic structure was seen within the third ventricle, distending it []. Furthermore, an eccentric mural nodule of intermediate signal intensity was identified. This nodule was thought to represent the scolex.\nA diagnosis of third ventricular cysticercosis causing obstructive hydrocephalus was made.\nThe patient was then taken for surgical evacuation of the cysticercus. A right parietal approach was taken with the plan of approaching the third ventricle through the right lateral ventricle. However, during ventriculostomy, no lesion was seen within the third ventricle. A VP shunt was placed in situ to decompress the hydrocephalus and the procedure was abandoned. An endoscopic third ventriculostomy was not attempted due to lack of adequate expertise and equipment.\nMRI of the brain was repeated to locate the cysticercus. The third ventricle did not reveal the neurocysticercus []. The cysticercus was now seen to have migrated into the occipital horn of the right lateral ventricle []. However, the hydrocephalus was seen to have decreased in severity compared to the previous scan.\nThe patient then received antihelminthic therapy and a repeat MRI performed after 2 months did not reveal any evidence of neurocysticercosis.