Although cysticercosis is the most common parasitic disease affecting the central nervous system, spinal cysticercosis is rare. A rare form of spinal cysticercosis involving the whole spinal canal is presented. A 45-year-old Korean male had a history of intracranial cysticercosis and showed progressive paraparesis. Spinal magnetic resonance scan showed multiple cysts compressing the spinal cord from C1 to L1. Three different levels (C1-2, T1-3, and T11-L1) required operation. Histopathological examination confirmed cysticercosis. The patient improved markedly after surgery

Alsina

Colli

Dong Ah Shin

Garcia

Hyun Chul Shin

Mohanty

Singh

Sotelo

Yong

Yonsei Medical Journal

English

PubMed

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A Case of Extensive Spinal Cysticercosis Involving the Whole Spinal Canal in a Patient with a History of Cerebral Cysticercosis

Although cysticercosis is the most common parasitic disease affecting the central nervous system, spinal cysticercosis is rare. A rare form of spinal cysticercosis involving the whole spinal canal is presented. A 45-year-old Korean male had a history of intracranial cysticercosis and showed progressive paraparesis. Spinal magnetic resonance scan showed multiple cysts compressing the spinal cord from C1 to L1. Three different levels (C1-2, T1-3, and T11-L1) required operation. Histopathological examination confirmed cysticercosis. The patient improved markedly after surgeryope

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Yonsei Med J   http://www.eymj.org    Volume 50   Number 4   August 2009582Cysticercosis is a systemic illness caused by Taenia Solium larvae dissemination.1Although it can occur in almost any tissue, neurocysticercosis (NCC) is the mostclinically important manifestation and may present with dramatic findings due toskull and spinal canal confines.2 Though NCC is not rare in Korea,3 spinalneurocysticercosis (SNCC) is (1.5%).3 Its rarity has been explained by the factthat intracranial cysticerci do not pass through the subarachnoid space at thecervical level due to its size.1 Although cases of SNCC have previously beenreported, there has been no report of whole spinal canal involvement requiringmultiple operations. We present such a rare case.A 45-year-old Korean male presented with a 3-month history of progressivelower limb weakness and voiding difficulty. Fifteen years ago, he had beendiagnosed with intracranial cysticercosis. At that time, brain magnetic resonanceimaging (MRI) revealed mild hydrocephalus and focal meningitis in the leftcerebello-pontine and ambient cistern. A enzyme-linked immunosorbent assay ofhos cerebrospinal fluid test confirmed cysticercosis,4,5 and the patient completed 2cycles of oral praziquantel (PZQ; 50 mg/kg per day in 3 divided doses for 14days)6 and carbamazepine (CMZ; 400 mg per day in 2 divided doses daily) forseizure prophylaxis. He was well until severe headache recurred 10 years later.Brain MRI then revealed slightly aggravated hydroce-phalus. Reactivated NCCCase Report DOI 10.3349/ymj.2009.50.4.582pISSN: 0513-5796, eISSN: 1976-2437 Yonsei Med J 50(4): 582-584, 2009A Case of Extensive Spinal Cysticercosis Involving the Whole Spinal Canal in a Patient with a History of Cerebral CysticercosisDong Ah Shin1 and Hyun Chul Shin21Department of Neurosurgery, CHA University College of Medicine, Pocheon; 2Department of Neurosurgery, Sungkyunkwan University Collegeof Medicine, Seoul, Korea.Although cysticercosis is the most common parasitic disease affecting the central nervous system, spinal cysticercosisis rare. A rare form of spinal cysticercosis involving the whole spinal canal is presented. A 45-year-old Korean malehad a history of intracranial cysticercosis and showed progressive paraparesis. Spinal magnetic resonance scanshowed multiple cysts compressing the spinal cord from C1 to L1. Three different levels (C1-2, T1-3, and T11-L1)required operation. Histopathological examination confirmed cysticercosis. The patient improved markedly aftersurgery.Key Words : Neurocysticercosis, subarachnoid space, spine, central nervous system parasitici infectionsReceived: September 28, 2007Revised: December 10, 2007Accepted: December 10, 2007Corresponding author: Dr. Hyun Chul Shin,Department of Neurosurgery,Sungkyunkwan University College ofMedicine, 78 Saemunan-gil, Jongno-gu,Seoul 110-746, Korea. Tel: 82-2-2001-2159, Fax: 82-2-393-9979E-mail: imdrshin@yuhs.ac∙The authors have no financial conflicts ofinterest.© Copyright:Yonsei University College of Medicine 2009INTRODUCTIONCASE REPORTwas suspected as the patient complained of severe headache,CSF examination showed inflammation, and a CSFELISA test confirmed cysticercosis. The patient received 3cycles of albendazole (ABZ; 15 mg/kg per day in 3divided doses for 7 days), and his antiepileptic was changedto valproic acid (VPA; 900 mg per day in 3 divided dosesdaily). The patient recovered well until this current presen-tation. Neurological examination revealed Grade 3 lowerlimb motor weakness, no sensory abnormality, and alertmental state. Compared with prior MRI results, brain MRIrevealed unchanged hydrocephalus and no evidence ofcyst or meningitis. However, T2-weighted MR images ofthe spine demonstrated multiple cysts compressing thespinal cord from C1 to L1 (Fig. 1). The patient underwentsurgical removal. Laminectomy from C1 to C2, T1 to T3,and T11 to L1 was performed. Linear incision was madeon the dura. Arachnoiditis was noticed focally. Severalwhite encapsulated cysts containing clear fluid adhered tothe arachnoid membrane and were dissected with difficulty,but the rest was easily removed. Histopathological exa-mination confirmed cysticercosis. Albendazole (ABZ; 15mg/kg per day in 3 divided doses for 14 days) was pres-cribed postoperatively. The patient improved enough toambulate with a walker and regained urinary function. Cysticercosis is the most common parasitic disease affect-ing the central nervous system.1 SNCC is rare comparedwith intracranial NCC, and its incidence is known to be 0.7to 5.85%.7 Low incidence of SNCC is explained by the“sieve effect.”1 The majority of cysticerci cannot passthrough the subarachnoid space at the cervical level due toits size and the physiological sieve.1 CSF reflux at thecraniovertebral junction, which propels floating cysts backinto the intracranial space rather than the spinal canal, is ananother possible reason of why SNCC is rare. On the otherhand, there are several possible mechanisms of cysticer-cosis spinal invasion. 1) Ventricular cysticerci pass throughthe Magendie or Luschka foramen, and migrate via gravitythrough the subarachnoid space to inoculate the spinalcord.1,7 The subarachnoid form is explained by this me-chanism. The subarachnoid form usually occurs at thecervical level, but our present case demonstrated that it cango as far as the cauda equina. 2) Hematogenous spread hasbeen regarded as the invading mode of the intramedullaryform. Spinal blood flow is richest at the thoracic level,which is the most common level for the intramedullaryform.8 3) Intraventricular hypertension enables migrationthrough a dilated ependymal canal into the spinal cord. Italso explains the invading mode of the intramedullaryform.1 Besides, there are several prodromal conditions thatmake cysticercosis readily invade the spinal contents.These include NCC-related hydrocephalus and/or menin-gitis, and use of antiepileptics and anithelminithics. SNCCoccurs in patients with a prior diagnosis of intracranialNCC in approximately 75% of cases; direct extension ofintracranial NCC is implied as the source.1 AntiepilepticExtensive Spinal CysticercosisYonsei Med J   http://www.eymj.org    Volume 50   Number 4   August 2009 583DISCUSSIONFig. 1. T2-weighted MR images of the whole spine, which demonstrate cystslocated at the anterior subarachnoid space of T1-2 and posterior arachnoidspace of C2, T5-T7, L1, and L2. Increased signal intensity, which indicates edemaof the spinal cord, is noted at the level of T2 through T4 and T9 to T10 (arrows).drugs, such as carbamazepine and phenytoin, can alterimmune function, and therefore, affect susceptibility toparasitic infestation. Although a recent randomized con-trolled trial demonstrated the benefit of antihelminthictherapy in patients harboring viable cysts within the brainparenchyma, it is thought to increase inflammation becauseof cyst involution, leading to worsening clinical states,which might accelerate dissemination of other viablecysticerci.9,10 The long term prognosis of neurocysticercosisis still not satisfactory.3,6,10 Our patient had a long history ofintracranial NCC with hydrocephalus and meningitis. Inaddition, he had long term administration of antihelminthicand antiepileptic drugs. These are thought to be the causa-tive factors of extensive spinal involvement in our patient.Although the subarachnoid form has been frequentlyreported, there is no previous report to document SNCCinvolving the whole spinal canal. This case demonstrates aserious manifestation and successful surgical managementof SNCC secondary to intracranial NCC.1. Colli BO, Valença MM, Carlotti CG Jr, Machado HR, AssiratiJA Jr. Spinal cord cysticercosis: neurosurgical aspects. Neuro-surg Focus 2002;12:e9.2. Alsina GA, Johnson JP, McBride DQ, Rhoten PR, MehringerCM, Stokes JK. Spinal neurocysticercosis. Neurosurg Focus 2002;12:e8.3. Kim SK, Wang KC, Paek SH, Hong KS, Cho BK. Outcomes ofmedical treatment of neurocysticercosis: a study of 65 cases inCheju Island, Korea. Surg Neurol 1999;52:563-9.4. Lee JH, Kong Y, Ryu JY, Cho SY. Applicability of ABC-ELISAand protein A-ELISA in serological diagnosis of cysticercosis.Korean J Parasitol 1993;31:49-56.5. Yong TS, Yeo IS, Seo JH, Chang JK, Lee JS, Kim TS, et al.Serodiagnosis of cysticercosis by ELISA-inhibition test usingmonoclonal antibodies. Korean J Parasitol 1993;31:149-56.6. Rim HJ, Lee JS, Joo KH, Kim SJ, Won CR, Park CY. Thera-peutic Trial Of Praziquantal (Embay 8440; Biltricide(R)) On TheDermal And Cerebral Human Cysticercosis. KisaengchunghakChapchi 1982;20:169-90.7. Mohanty A, Das S, Kolluri VR, Das BS. Spinal extraduralcysticercosis: a case report. Spinal Cord 1998;36:285-7.8. Sotelo J, Guerrero V, Rubio F. Neurocysticercosis: a new classifi-cation based on active and inactive forms. A study of 753 cases.Arch Intern Med 1985;145:442-5.9. Garcia HH, Pretell EJ, Gilman RH, Martinez SM, Moulton LH,Del Brutto OH, et al. A trial of antiparasitic treatment to reducethe rate of seizures due to cerebral cysticercosis. N Engl J Med2004;350:249-58.10. Singh G, Sander JW. Anticysticercal treatment and seizures inneurocysticercosis. Lancet Neurol 2004;3:207-8.Dong Ah Shin and Hyun Chul ShinYonsei Med J   http://www.eymj.org    Volume 50   Number 4   August 2009584REFERENCES

A case of extensive spinal cysticercosis involving the whole spinal canal in a patient with a history of cerebral cysticercosis

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A Case of Extensive Spinal Cysticercosis Involving the Whole Spinal Canal in a Patient with a History of Cerebral Cysticercosis

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