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Neurocysticercosis Clinical Presentation

  • Author: Mohammed J Zafar, MD, FAAN, FACP; Chief Editor: Niranjan N Singh, MD, DM  more...
 
Updated: Jun 14, 2016
 

History

Neurocysticercosis is a pleomorphic disease, although it sometimes produces no clinical manifestation. This pleomorphism is due to variations in the locations of the lesions, the number of parasites, and the host's immune response.[3]

Many patients are asymptomatic; others report vague symptoms such as headache or dizziness. The onset of symptoms is usually subacute to chronic, with the exception of seizures, which present in an acute fashion. Possible symptomatic presentations are briefly reviewed below.

Epilepsy

Epilepsy is the most common presentation (70%) of neurocysticercosis and is also a complication of the disease.[14] Neurocysticercosis is the leading cause of adult-onset epilepsy and is probably one of the most frequent causes of childhood epilepsy in the world.

Seizures secondary to neurocysticercosis may be generalized or partial. Simple and complex partial seizures may be associated with the presence of a single lesion. Generalized seizures are usually tonic-clonic; this is thought to be related to the presence of multiple lesions. However, irritation of focal cortical tissue by one of the lesions most probably leads to focal onset with secondary generalization. Myoclonic seizures also have been described.

Go to First Adult Seizure for complete information on this topic.

Headache

Headaches may be associated with intracranial hypertension and are indicative of hydrocephalus; they may also result from meningitis. Chronic headaches may be associated with nausea and vomiting (simulating migraines).

Intracranial hypertension

Most often, intracranial hypertension is due to obstruction of cerebrospinal fluid (CSF) circulation caused by basal or ventricular cysticercosis. It may also result from large cysts displacing midline structures, granular ependymitis, arachnoiditis, or the so-called cysticercotic encephalitis caused by the inflammatory response to a massive infestation of cerebral parenchyma with cysticerci. Affected patients may have seizures and deterioration of their mental status, mainly due to the host's inflammatory reaction as an exaggerated response to the massive infestation.

Diplopia may also result from intracranial hypertension or arachnoiditis producing entrapment or compression of cranial nerves III, IV, or VI.

Strokes

Ischemic cerebrovascular complications of neurocysticercosis include lacunar infarcts[15] and large cerebral infarcts due to occlusion or vascular damage. Hemorrhage can also occur and has been reported as a result of rupture of mycotic aneurysms of the basilar artery. Strokes may be responsible for paresis or plegias, involuntary movements, gait disturbances, or paresthesias.[16]

Neuropsychiatric disturbances

Neuropsychiatric dysfunction can range from poor performance on neuropsychologic tests to severe dementia. These symptoms appear to be related more to the presence of intracranial hypertension than to the number or location of parasites in the brain.

Hydrocephalus

Ten to thirty percent of patients with neurocysticercosis develop communicating hydrocephalus due to inflammation and fibrosis of the arachnoid villi or inflammatory reaction to the meninges and subsequent occlusion of the foramina of Luschka and Magendie. Noncommunicating hydrocephalus may be a consequence of intraventricular cysts.

Presentations of other forms of neurocysticercosis

Patients with intrasellar neurocysticercosis present with ophthalmologic and endocrinologic manifestations mimicking those of pituitary tumors.

Spinal neurocysticercosis is rare and may be either intramedullary or extramedullary. The extramedullary form is the most frequent and is responsible of symptoms of spinal dysfunction such as radicular pain, weakness, and paresthesias. Intramedullary presentation may cause paraparesis, sensory deficits with a level, and sphincter disturbances.

Ocular cysticercosis occurs most commonly in the subretinal space. Patients may present with ocular pain, decreased visual acuity, visual field defects, or monocular blindness.

Systemic cysticercosis is most common in the Asian continent. The parasites may be located in the subcutaneous tissue or muscle. Peripheral nerve involvement as well as involvement of the liver or spleen have been reported.

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Physical Examination

Twenty percent or less of infected patients with neurocysticercosis have abnormal neurologic findings. Physical findings depend on where the cyst is located in the nervous system and include the following:

  • Cognitive decline
  • Dysarthria
  • Extraocular movement palsy or paresis
  • Hemiparesis or hemiplegia, which may be related to stroke, or Todd paralysis
  • Hemisensory loss
  • Movement disorders
  • Hyper/hyporeflexia
  • Gait disturbances
  • Meningeal signs
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Contributor Information and Disclosures
Author

Mohammed J Zafar, MD, FAAN, FACP Associate Clinical Professor of Medicine, West Michigan University School of Medicine; Neurologist, Clinical Neurophysiologist and Neuroimager, Kalamazoo Nerve Center, PLLC

Mohammed J Zafar, MD, FAAN, FACP is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Physicians, American Institute of Ultrasound in Medicine, American Society of Neuroimaging, Michigan State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Florian P Thomas, MD, PhD, Drmed, MA, MS Director, National MS Society Multiple Sclerosis Center; Professor and Director, Clinical Research Unit, Department of Neurology, Adjunct Professor of Physical Therapy, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, Drmed, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MD, DM Associate Professor of Neurology, University of Missouri-Columbia School of Medicine

Niranjan N Singh, MD, DM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

References
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  2. Baird RA, Wiebe S, Zunt JR, Halperin JJ, Gronseth G, Roos KL. Evidence-based guideline: Treatment of parenchymal neurocysticercosis: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013 Apr 9. 80(15):1424-1429. [Medline].

  3. Chaoshuang L, Zhixin Z, Xiaohong W, Zhanlian H, Zhiliang G. Clinical analysis of 52 cases of neurocysticercosis. Trop Doct. 2008 Jul. 38(3):192-4. [Medline].

  4. Tian XJ, Li JY, Huang Y, Xue YP. Preliminary analysis of cerebrospinal fluid proteome in patients with neurocysticercosis. Chin Med J (Engl). 2009 May 5. 122(9):1003-8. [Medline].

  5. Odermatt P, Preux PM, Druet-Cabanac M. Treatment of neurocysticercosis: a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2008 Sep. 79(9):978. [Medline].

  6. Garcia HH, Pretell EJ, Gilman RH, Martinez SM, Moulton LH, Del Brutto OH, et al. A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis. N Engl J Med. 2004 Jan 15. 350(3):249-58. [Medline].

  7. White AC Jr. New developments in the management of neurocysticercosis. J Infect Dis. 2009 May 1. 199(9):1261-2. [Medline].

  8. Rangel-Castilla L, Serpa JA, Gopinath SP, Graviss EA, Diaz-Marchan P, White AC Jr. Contemporary neurosurgical approaches to neurocysticercosis. Am J Trop Med Hyg. 2009 Mar. 80(3):373-8. [Medline].

  9. Gubbay AD, Brophy BP, Henley S, Sage M. Neurocysticercosis. J Clin Neurosci. 1998 Apr. 5(2):203-7. [Medline].

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  11. Del Brutto OH, Garcia E, Talamas O, Sotelo J. Sex-related severity of inflammation in parenchymal brain cysticercosis. Arch Intern Med. 1988 Mar. 148(3):544-6. [Medline].

  12. Gaffo AL, Guillen-Pinto D, Campos-Olazabal P, Burneo JG. [Cysticercosis as the main cause of partial seizures in children in Peru]. Rev Neurol. 2004 Nov 16-30. 39(10):924-6. [Medline].

  13. Bickerstaff ER, Cloake PC, Hughes B, Smith WT. The racemose form of cerebral cysticercosis. Brain. 1952 Mar. 75(1):1-18. [Medline].

  14. Del Brutto OH, Santibanez R, Noboa CA, Aguirre R, Diaz E, Alarcon TA. Epilepsy due to neurocysticercosis: analysis of 203 patients. Neurology. 1992 Feb. 42(2):389-92. [Medline].

  15. Barinagarrementeria F, Del Brutto OH. Lacunar syndrome due to neurocysticercosis. Arch Neurol. 1989 Apr. 46(4):415-7. [Medline].

  16. Barinagarrementeria F, Cantu C. Neurocysticercosis as a cause of stroke. Stroke. 1992 Aug. 23(8):1180-1. [Medline].

  17. Garcia HH, Martinez SM, eds. Taenia solium Taeniasis/Cysticercosis. 2nd ed. Lima, Peru: Editorial Universo; 1999.

  18. Garg RK. Treatment of neurocysticercosis: is it beneficial?. Expert Rev Anti Infect Ther. 2008 Aug. 6(4):435-40. [Medline].

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Massive nonencephalitic neurocysticercosis. Photo courtesy of Cysticercosis Working Group in Peru.
Computed tomographic (CT) scan of the brain in a patient who presented with an episode of generalized tonic-clonic seizure. Note the calcified lesion in the left parieto-occipital region. Subsequent evaluation confirmed the diagnosis of neurocysticercosis.
T2-weighted magnetic resonance image (MRI) of the brain showing the presence of increased signal as a result of edema in the right frontal region; subsequent studies found a cysticercus in that location.
Magnetic resonance image (MRI) of the brain in a patient who presented with an episode of generalized tonic-clonic seizure. Note the cyst in the left parieto-occipital region with perilesional edema.
 
 
 
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