Disseminated neurocysticercosis (various stages) with hydrocephalus
Presentation
Chronic headache, multiple episode of seizure, altered mental status, no history of fever.
Patient Data
CT Brain (digitized images)
Multiple non-enhancing smooth thin-walled cysts are isodense to CSF with eccentric hyperdense scolex involving the bilateral cerebral and cerebellar hemisphere with no perilesional edema.
There are multiple non-enhancing hyperdense nodules without perilesional edema involving bilateral cerebral hemispheres.
There is a small nodular hyperdense lesion in the frontal horn of right lateral ventricle.
Bilateral lateral ventricles, third and fourth ventricle are dilated with periventricular hypodensities.
There is asymmetrical dilation of the left ambient cistern.
There are multiple non-enhancing cystic lesions of various sizes that are isointense to CSF on T1 and T2/FLAIR with discrete, eccentric hyperintense nodules (cyst with dot sign) involving the bilateral cerebral and cerebellar hemisphere striking “salt and pepper brain” appearance. There is no evidence of perilesional edema.
There is asymmetrical dilation of the left ambient cistern with cystic lesion and scolex within, and multiple cystic lesions with scolex also seen in the right Sylvian fissure and the bilateral cortical sulci.
Bilateral lateral ventricles, third and fourth ventricle are dilated with periventricular signal intensities.
Case Discussion
Aunt Minnie: typical disseminated parenchymal, intraventricular and subarachnoid space neurocysticercosis with hydrocephalus.
Neurocysticercosis (NCC) has four recognized stages 1:
vesicular (viable larva): cyst with scolex, no edema or enhancement
colloidal vesicular (dying larva): Intense inflammation, edema, ring enhancement
granular nodular (healing): cyst involutes, edema diminishes, faint rim enhancement
nodular calcifying (healed): quiescent fibro-calcified nodule, hyperdense on CT and black dots on MRI
NCC may sometimes present as multilobulated, variably sized, grape-like lesion in the basal cisterns associated with the arachnoiditis with fibrosis and scarring as demonstrates rim enhancement around the cysts and along the brain surfaces and causes obstructive hydrocephalus which is called “Racemose” NCC 1.
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