Presentation
Headaches, GCS 15.
Patient Data
Intra-axial irregular rim-enhancing focus within the left parietal lobe with relatively thick peripheral enhancement and a central cystic focus that does not demonstrate diffusion restriction. Smaller peripheral lobulations are present superolaterally with thinner peripheral enhancement and central foci demonstrating restricted diffusion.
Stippled susceptibilities on SWI within the enhancing capsule suggestive of hemosiderin.
The enhancing capsule is of moderately low signal on T2, with the smaller peripheral lobulations associated with higher T2 signal and thinner walls. Additionally, there is mild but diffuse adjacent sulcal leptomeningeal enhancement posterosuperiorly.
Moderate surrounding vasogenic edema in the left parietal lobe with patchy extension of high FLAIR signal to involve the posterior corpus callosum body without significant extension across the midline. There is effacement of the lateral ventricle on the left with midline shift to the right.
This patient subsequently had the lesion biopsied.
HISTOLOGY
MICROSCOPIC: Cortical white matter with a dense fibrocollagenous cyst-like structure containing non-viable racemose cysticercus organism, characterized by an undulating cuticular layer overlying cellular and fibrillar layers of the parasite. No scolices or refractile hooklets identified. The surrounding inflammatory response consists of neutrophils, lymphocytes, histiocytes and epithelioid cells and necrotic debris. No caseous necrosis or multinucleated giant cells identified. Features are consistent with neurocysticercosis with inflammatory response.
Case Discussion
This is an atypical case of neurocysticercosis with an isolated lesion. Differentials are of tuberculoma, abscess or primary tumor (GBM). It is important to consider neurocysticercosis especially with a history of new onset seizures and travel to/from geographically endemic regions 1.
Thank you to Dr Han Xin Lau for contributing this case with me.
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