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Table of Contents   
ORIGINAL ARTICLE  
Year : 2010  |  Volume : 3  |  Issue : 2  |  Page : 58-63
Clinico-radiological profile and treatment outcomes in neurocysticercosis: A study of 40 patients


1 Department of Medicine, MNR Medical College, Sangareddy, Andhra Pradesh, India
2 Department of Medicine, Government Medical College, Nagpur, Maharashtra, India

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Date of Web Publication1-Mar-2011
 

   Abstract 

Aims: This study was aimed to study the clinical and radiological profile of neurocysticercosis and outcomes of treatment in neurocysticercosis. Settings and Design: A prospective observational study conducted in a tertiary care hospital. Subjects and Methods: Forty patients coming under Definitive or Probable Diagnosis of neurocysticercosis as per the revised diagnostic criteria for neurocysticercosis were included in this study. Cinical history, physical examination and neuroimaging [computed tomography (CT) or magnetic resonance imaging (MRI)] studies were done at the beginning. Patients were treated with albendazole, corticosteroids and antiepileptic drugs. They were followed up clinically for 3 months and neuroimaging study was repeated 3 months after albendazole therapy. Results: Definitive cases were 28 (70%) and probable cases were 12 (30%). Male:female ratio was 2.07. Mean age of 29.62 ± 9.08 years. The commonest presentation was seizures in 38 (95%); 29 (72.5%) patients had a single lesion and 11 (27.5%) had multiple lesions in initial imaging study. Commonest site of lesion was parietal lobe (45%). Most common stage of presentation was colloidal (55%). Thirty-seven (92.5%) patients were free of seizures at the end of 3 months. At the end of 3 months, 23 (57.5%) patients had radiological resolution (complete resolution + partial resolution + calcification). Conclusions: Neurocysticercosis usually affects young persons, mostly in the third decade, being equally common among vegetarians. Most common clinical manifestation is seizures. Single lesion is more common than multiple lesions, commonly presenting in colloidal stage. Clinical and radiological response to 4 weeks therapy with albendazole is quite satisfactory. All cases of young and adult onset epilepsy in tropical countries should be investigated for neurocysticercosis.

Keywords: Albendazole, colloidal stage, neurocysticercosis, seizures

How to cite this article:
Patil TB, Paithankar MM. Clinico-radiological profile and treatment outcomes in neurocysticercosis: A study of 40 patients. Ann Trop Med Public Health 2010;3:58-63

How to cite this URL:
Patil TB, Paithankar MM. Clinico-radiological profile and treatment outcomes in neurocysticercosis: A study of 40 patients. Ann Trop Med Public Health [serial online] 2010 [cited 2018 May 22];3:58-63. Available from: http://www.atmph.org/text.asp?2010/3/2/58/77186

   Introduction Top


Neurocysticercosis is the commonest parasitic disease of nervous system. [1] The age-adjusted prevalence of active epilepsy in tropical countries ranges from 10 to 15 per 1000 inhabitants, almost twice the level in western countries. [2] Neurocysticercosis has been estimated to cause at least 50,000 deaths worldwide annually. [2] In India, neurocysticercosis has been identified as a cause of 2.2-6% unselected cases of seizures. [3]

Neurocysticercosis is caused by the larval stage (cysticerci) of the pork tapeworm Taenia solium. Clinical manifestations of neurocysticercosis are varied due to individual differences in the number, size, and topography of lesions and in the severity of the host's immune response to the parasites.

This study was aimed to determine the clinical and radiological profile of neurocysticercosis and outcomes of treatment in neurocysticercosis.


   Materials and Methods Top


This was a prospective observational study conducted over a period of 1 year from June 2008 to June 2009 and included 40 patients.

Inclusion criteria

Patients coming under Definitive or Probable Diagnosis of neurocysticercosis as per the revised diagnostic criteria for neurocysticercosis [4] [Table 1] were included in this study. However, histologic demonstration of the parasite from biopsy of a brain lesion was not done, as this is an invasive procedure. Also, serum enzyme-linked immunoelectrotransfer blot (EITB) and cerebrospinal fluid enzyme-linked immunosorbent assay (CSF ELISA) test were not done due to nonavailability of these tests in the institute and non-affordability of the patients. Thus, the diagnosis was based on clinical and radiological features.
Table 1: Revised diagnostic criteria for neurocysticercosis[4]

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Exclusion criteria

Patients with tuberculosis, HIV reactive patients and patients with a known malignancy were excluded due to greater chances of intracranial space-occupying lesions in these patients.

A detailed medical history with emphasis on the description of the seizure, general examination and neurological examination was performed. Diagnostic evaluation included hemoglobin, peripheral blood smear, total and differential leukocyte counts, microscopic examination of stool done thrice for teniasis, work up for tuberculosis (erythrocyte sedimentation rate, Mantoux test, chest radiograph), HIV I and II, contrast-enhanced computed tomography (CT) scan of brain or magnetic resonance imaging (MRI) brain. Number, site, stage, size of the lesions, presence of scolex and perilesional edema were noted. All patients received albendazole at a dose of 15 mg/kg body weight/day in three divided doses for 28 days and oral prednisolone 2 mg/kg/day for initial 5 days of therapy. Antiepileptic drugs were given. Patients were followed up regularly for 3 months after the completion of albendazole therapy. Imaging study was repeated 3 months after initiation of albendazole therapy. Following were considered as indicators of therapeutic outcome.

Radiological outcome

  1. Complete resolution - Disappearance of lesion.
  2. Partial resolution - Reduction in size or number of lesions by at least 50% or more of the original.
  3. No resolution - No reduction or less than 50% decrease in the size or number of original lesions.
  4. Calcification of the lesion - Appearance of small calcified speck without edema.
Clinical outcome was measured in terms of recurrence of seizures, based on objective reports from the patients.


   Results Top


There were 40 patients included in the study, out of whom definitive cases were 28 (70%) and probable cases were 12 (30%). Distribution of cases as per the criteria for diagnosis of neurocysticercosis is shown in [Table 2].
Table 2: Distribution of cases as per the criteria for diagnosis of neurocysticercosis

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Patient characteristics

A total of 40 patients were included in this study, out of whom 27 (67.5%) were males and 13 (32.5%) were females. The male:female ratio was 2.07. The subject age varied from 16 to 55 years, with a mean age of 29.62 ± 9.08 years. Maximum patients were in the age group of 21-30 years (45%), followed by 31-40 years (25%), 11-20 years (15%), 41-50 years (12.5%) and >50 years (2.5%). Majority (50%) of the cases were of lower socioeconomic strata, followed by upper lower (27.5%), lower middle (15%), upper middle (5%) and upper class (2.5%). Nineteen (47.5%) were pure vegetarians and 21 (52.5%) patients took a mixed diet. None of the patients were pork eaters. None of the patients had domestic or occupational exposure to pigs. Out of the 40 patients, 26 (65%) were rural and 14 (35%) were urban.

The presenting clinical features are shown in [Table 3]. There were 19 (47.5%) patients who had simple partial seizures, 3 (7.5%) patients had complex partial seizures, 4 (10%) had partial seizures with secondary generalization and 14 (35%) patients had primarily generalized seizures. In 6 (15%) patients, Jacksonian progression of seizure activity was seen. Only 5 (12.5%) patients had postictal weakness (Todd's paresis) lasting for few minutes to 8 hours. Status epilepticus was present in 3 (7.5%) patients. Papilledema was observed in 4 (10%) patients. Ocular cysticercosis was not seen in any patient.
Table 3: Symptoms of the patients at presentation

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Investigations

Mean hemoglobin level was 10.66 ± 2.54 g/dl. Eosinophilic percentage was raised (>5%) in 4 (10%) patients. Stool microscopy for teniasis was negative in all patients.

Characteristics of first CT scan/MRI

Thirty-five (87.5%) patients underwent contrast-enhanced CT scan and 5 (12.5%) patients underwent MRI scan at the beginning of the study. Out of the 40 patients, 29 (72.5%) had a single lesion and 11 (27.5%) had multiple lesions in initial imaging study.

Commonest site of lesion was parietal lobe (45%). Eleven patients (27.5%) had lesions involving multiple lobes and 9 (22.5%) patients had frontal lobe lesions. Only one patient each had a lesion in temporal and occipital lobes. Most common stage of presentation was colloidal (55%) followed by vesicular (12.5%) and granular-nodular (5%), whereas 27.5% patients had lesions in multiple stages of development. Out of the 40 patients, 24 (60%) were found to have lesions ≤10 mm, whereas 16 (40%) had lesions >10 mm. Scolex was seen in initial imaging study in 15 (37.5%) patients. Twenty-six (65%) patients had perilesional edema at the time of presentation. Perilesional edema was ≤5 mm in 24 (60%) patients and >5 mm in 2 (5%) patients, whereas 14 (35%) patients had no perilesional edema. None of the patients had mass effect due to lesion.

Extraneural cysticercosis

Two (5%) patients had evidence of extraneural cysticercosis. One patient had palpable muscle nodule on the anterior abdominal wall which was proved to be cysticercosis on aspiration cytology. Other patient was found to have vesicular cysticercal lesions with central scolex in tongue muscles and paravertebral muscles of neck on MRI scan.

Clinical outcome

Clinical outcome was assessed on the basis of recurrence of seizures, based on objective reports from patients. Thirty-seven (92.5%) patients were free of seizures, whereas three patients (7.5%) had recurrence of seizures, at the end of 3 months. All 29 patients who had a single lesion in the initial imaging study were seizure free and 8 out of 11 patients with multiple lesions in initial imaging study were free of seizures at the end of 3 months. Out of the 29 patients with a single lesion who were seizure free, 13 (44.82%) had complete resolution of the lesion on follow-up imaging study at the end of 3 months; 4 (13.79%) had partial resolution; in 2 (6.89%) patients, the lesions underwent calcification and the lesions remained unaltered in 10 (34.48%) patients.

Out of 8 patients with multiple lesions who were seizure free, 3 (37.5%) had partial resolution and 1 (12.5%) had calcification of lesion.

Three (7.5%) patients had recurrence of seizures during the 3 month follow-up period. All these patients had multiple lesions in the initial imaging study and the lesions were unaltered in the follow-up study at the end of 3 months.

No patient developed signs of elevated intracranial pressure during or soon after therapy. Six patients (15%) developed headache on day 3-4 of treatment with cysticidal drugs, not associated with any other feature of raised intracranial pressure. Interruption of the therapy was not required in any of these cases.

Radiological outcome

Radiological follow-up at 3 months in patients with single lesion (n = 29) and in patients with multiple lesions (n = 11) is shown in [Table 4] and [Table 5], respectively. At the end of 3 months, only one patient (2.5%) had perilesional edema >5 mm and 3 (7.5%) patients had perilesional edema ≤5 mm. None of the patients had shown appearance of new lesions on follow-up imaging study.
Table 4: Radiological follow-up at 3 months in patients with single lesion (n = 29)

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Table 5: Radiological follow-up at 3 months in patients with multiple lesions (n = 11)

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   Discussion Top


The subject age varied from 16 to 55 years, with a mean age of 29.62 ± 9.08 years. Maximum patients were in the age group of 21-30 years. Mean age of patients in other studies across the globe was 33 years [5] (27 ± 18 years). [6] In an adult case series from India, the mean age of patients was 29.1 years [3] (28 ± 12 years; range 12-66 years). [7] These data show that neurocysticercosis is common in children and young adults worldwide. Thus, the age distribution of the patients in the present study was similar to other Indian as well global studies.

Cysticercosis is generally a disease of lower socioeconomic conditions, associated with poor hygiene and sanitation. In a study from Kerala, Kuruvilla et al. [8] found that 73% patients belonged to lower socioeconomic category. In other studies from Chandigarh, 69% and 82.7% of the patients were of lower socioeconomic strata. [9],[10] Majority (77.5%) of the cases in the present study were of lower socioeconomic class. Thus, the results are similar to other Indian studies.

Although cysticercosis has been reported to be higher among nonvegetarian people, especially pork eaters, many (46%) of our patients were pure vegetarians, and none of the patients consumed pork, thereby supporting the fact that feco-oral contamination is a major route of the disease. In a previous study from Chandigarh, 53.2% patients were documented as pure vegetarians. [10]

In a study from China, Chaoshuang et al. [11] found that urban population is at a higher risk than rural population. The percentages of urban patients in two Brazilian studies were 86.2% [12] and 93.8%. [13] Rajshekhar et al., [14] who studied active epilepsy as an index of burden of neurocysticercosis in Vellore district, India, found that the prevalence in urban clusters was more than twice in the rural cluster (6.23 vs. 3.04 per 1000).

Contrary to the current literature, the present study has a high percentage of rural patients, probably related to poor hygienic conditions and higher amount of fecal contamination of drinking water in the rural areas.

Seizures are reported as the most common symptom in neurocysticercosis, occurring in 70-90% of patients. Similarly, 38 (95%) patients in the current study presented with seizure as the chief complaint.

In the literature, partial seizures are the most commonly reported seizures in patients with single lesion neurocysticercosis. [10],[15],[16],[17] Majority (86.20%) of the patients with single lesion in this study also had partial seizures.

Papilledema was observed in 4 (8%) patients. Das et al. reported papilledema in 16.5% patients. [3]

Most of the studies in India deal with single lesion neurocysticercosis (solitary cysticercal granuloma). A study by Kuruvilla et al. [8] found single lesion in 40% and multiple lesions in 60% patients. Single lesion was present in 76% and multiple lesions in 24% patients in a study by Singhi et al. [16] Similarly, Kotokey et al. [18] reported single lesion in 66.66% and multiple lesions in 33.33% patients, and Rajshekhar et al. [14] reported single lesion in 60.88% and multiple lesions in 39.13% patients.

Thus, whereas most of the Latin American studies show that multiple lesion neurocysticercosis is common in that part of the world; most of the Indian studies show that single lesion neurocysticercosis is the more common form of disease in India.

The present study found single lesion in 72.5% patients and multiple lesions in 27.5% patients, showing that single lesion neurocysticercosis is more common than multiple lesions, which is in agreement with most other Indian studies.

Parietal lobe has been found to be the most common site of single lesion neurocysticercosis. [9],[10],[15],[19] In this study, 45% of the lesions were situated in the parietal lobe. Baranwal et al. and Singhi et al. reported parietal lobe involvement in 41% and 57.3% patients, respectively. [9],[10] Since most of the patients present with motor or sensorimotor seizures, distribution of lesions about the sensorimotor cortex is well expected. Less commonly reported sites are temporal lobe, basal ganglion, cerebellum, which was also observed in our study. [9],[10] Thus, the distribution of the lesion in this study was similar to that reported in other studies.

The most common stage of presentation was colloidal (55%). This can be explained by the fact that in colloidal stage, there is degeneration of cyst wall and active inflammation leading to seizures. In vesicular phase, there is little or no evidence of perilesional inflammation and the cellular immune response is suppressed, leaving these viable cysts asymptomatic for long. Thus, only 12.5% patients presented in the vesicular phase. Neurocysticercosis lesions usually measure 20 mm or less in their maximal dimension. Majority (60%) of the patients were found to have maximum lesion diameter ≤10 mm

The visualization of a scolex on CT scan confirms the diagnosis of neurocysticercosis. However, it was not seen in all the cases. It could be visualized in only 37.5% patients. Similar figures have been reported previously also. [19]

Thirty-seven (92.5%) patients were free of seizures, whereas three patients (7.5%) had recurrence of seizures, at the end of 3 months. The seizure recurrence in patients treated with albendazole in other studies was: 13%, [15] 56%, [5] 13%, [20] and 18%. [8] Thus, the seizure recurrence of 7.5% in the current study is lesser than that observed by other authors.

In this study, out of 40 patients, 20 (50%) had radiological resolution (complete resolution + partial resolution) at the end of 3 months, whereas 3 patients developed calcification of the lesions. The radiological resolution in various other studies at the end of 3 months was: 88%, [21] 87%, [22] 64.5%, [9] 62.5%, [23] and 60%. [24] The radiological resolution in 50% in the current study is thus less as compared to previous studies.


   Conclusions Top


It can be concluded from this study that neurocysticercosis usually affects young persons, mostly in the third decade. It is equally common among vegetarians. Most common clinical manifestation is seizures, partial seizures being most common in patients with single lesion and primarily generalized seizures in patients with multiple lesions. Single lesion is more common than multiple lesions, commonly presenting in colloidal stage (ring enhancing lesion). Clinical and radiological response to 4 weeks therapy with albendazole is quite satisfactory with control of seizures in 92.5% patients and radiological resolution in 57.5% patients at the end of 3 months. We recommend that all cases of young and adult onset epilepsy in tropical countries should be investigated for neurocysticercosis.

 
   References Top

1.Del Brutto OH, Sotelo J. Neurocysticercosis: An update. Rev Infect Dis 1988;10:1075-87.   Back to cited text no. 1
    
2. Roman G, Sotelo J, Del Brutto O, Flisser A, Dumas M, Wadia N, et al. A proposal to declare neurocysticercosis an international reportable disease. Bull WHO 2000;78:399-406.  Back to cited text no. 2
    
3.Das RR, Jain S, Maheshwari MC. Neurocysticercosis: An analysis of 206 cases from an Indian hospital. Ann Ind Acad Neurol 2001;4:95-8.   Back to cited text no. 3
    
4. Del Brutto OH, Rajshekhar V, White AC Jr, Tsang VC, Nash TE, Takayanagui OM, et al. Proposed diagnostic criteria for neurocysticercosis. Neurology 2001;57:177-83.  Back to cited text no. 4
    
5.Garcia HH, Pretell EJ, Gilman RH, Martinez SM, Moulton LH, Del Brutto OH, et al. Cysticercosis Working Group in Peru. A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis. N Engl J Med 2004;350:249-58.  Back to cited text no. 5
    
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7.Kaushal S, Rani A, Chopra SC, Singh G. Safety and efficacy of clobazam versus phenytoin-sodium in the antiepileptic drug treatment of solitary cysticercus granulomas. Neurol India 2006;54:157-60.  Back to cited text no. 7
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9.Baranwal AK, Singhi PD, Khandelwal N, Singhi SC. Albendazole therapy in children with focal seizures and single small enhancing computerized tomographic lesions: A randomized, placebo controlled, double blind trial. Pediatr Infect Dis J 1998;17:696-700.  Back to cited text no. 9
    
10.Singhi P, Dayal D, Khandelwal N. One week versus four weeks of albendazole therapy for neurocysticercosis in children: A randomized, placebo controlled double blind trial. Pediatr Infect Dis J 2003;22:268-72.   Back to cited text no. 10
    
11.Chaoshuang L, Zhixin Z, Xiaohongk W, Zhanlian H, Zhiliang G. Clinical analysis of 52 cases of neurocysticercosis. Trop Doct 2008;38:192-4.  Back to cited text no. 11
    
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13.Benedeti MR, Falavigna DL, Falavigna-Guilherme AL, Araújo SM. Epidemiological and clinical profile of neurocysticercosis patients assisted by the Hospital Universitário Regional de Maringá, Paraná, Brazil. Arq Neuropsiquiatr 2007;65:124-9.  Back to cited text no. 13
    
14.Rajshekhar V, Raghava MV, Prabhakaran V, Oommen A, Muliyil J. Active epilepsy as an index of burden of neurocysticercosis in Vellore district, India. Neurology 2006;67:2135-9.   Back to cited text no. 14
    
15.Gogia S, Talukdar B, Choudhury V. Neurocysticercosis in children: Clinical findings and response to albendazole therapy in a randomized, double blind, placebo controlled trial in newly diagnosed cases. Trans R Soc Trop Med Hyg 2003;97:416-21.  Back to cited text no. 15
    
16.Singhi P, Ray M, Singhi S, Khandelwal N. Clinical spectrum of 500 children with neurocysticercosis and response to albendazole therapy. J Child Neurol 2000;15:207-13.  Back to cited text no. 16
    
17.Singh MK, Garg RK, Nath G, Verma DN, Misra S. Single small enhancing computed tomographic lesions in Indian patients with new onset seizures: A prospective follow-up in 75 patients. Seizure 2001;10:573-8.  Back to cited text no. 17
    
18.Kotokey RK, Lynrah KG, De A. A clinico-serological study of neurocysticercosis in patients with ring enhancing lesions in CT scan of brain J Assoc Physicians India 2006;54:366-70.  Back to cited text no. 18
    
19.Garg RK, Nag D. Single enhancing CT lesions in Indian patients with seizures: Clinical and radiological evaluation and follow-up. J Trop Pediatr 1998;44:204-10.  Back to cited text no. 19
    
20.Kalra V, Dua T, Kumar V. Efficacy of albendazole and short course dexamethasone treatment in children with 1 or 2 ring-enhancing lesions of neurocysticercosis: A randomized controlled trial. J Pediar 2003;143:111-4.  Back to cited text no. 20
    
21.Padma MV, Behari M, Misra NK, Ahuja GK. Albendazole in single CT ring lesions in epilepsy. Neurology 1994;44:1344-6.  Back to cited text no. 21
    
22.Padma MV, Behari M, Misra NK, Ahuja GK. Albendazole in neurocysticercosis. Natl Med J India 1995;8:255-8.  Back to cited text no. 22
    
23.Singhi P, Jain V, Khandelwal N. Corticosteroids versus albendazole for treatment of single small enhancing computed tomographic lesions in children with neurocysticercosis. J Child Neurol 2004;19:323-7.  Back to cited text no. 23
    
24.Sotelo J, Escobedo F, Penagos P. Albendazole vs praziquantel for therapy for neurocysticercosis: A controlled trial. Arch Neurol 1988;45:532-4.  Back to cited text no. 24
    

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Tushar B Patil
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DOI: 10.4103/1755-6783.77186

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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