Endoscopic Removal of Cisternal Neurocysticercal Cysts

Tooraj Gravori, M.D., Thomas Steineke, M.D., Ph.D.

Disclosures

Neurosurg Focus. 2002;12(6) 

In This Article

Clinical Material and Methods

We reviewed the medical records of three cases in which patients with symptomatic cisternal cysticercosis underwent endoscopic surgery, performed by the senior author (M.B.) at Harbor-UCLA Medical Center between January 1997 and December 2001. The patients were adults who had emigrated from Mexico to the Los Angeles area. In general, all three patients presented with progressive symptoms relating to mass effect and hydrocephalus. Each patient underwent placement of a ventriculostomy drain on admission for the treatment of hydrocephalus, and intravenous dexamethasone and antiepileptic therapy was initiated preoperatively. None received any anthelmintic agents. A summary of clinical data, neuroimaging findings, surgical management, and outcome is provided in Table 1 .

In each case, the cisternal cysts were approached via a transventricular corridor (Figs. 1-3). In two cases (Cases 1 [Fig. 1] and 3 [Fig. 3], Table 1 ), cysts superior or anterior to the third ventricle were reached by perforating the overlying septum pellucidum (Videos 1 and 3). In the patient in Case 2 (Video 2), the quadrigeminal cistern was entered by opening the extended trigone ependyma. Once within the cistern, the NCC cysts were easily identified. Both flexible-and rigid-lens endoscopes were used. All cysts were ruptured in the process of resection. The cystic yellowish content and scolex were evacuated. The cyst wall was resected using a micrograsper that extended through the working port of the endoscope.

Case 1. Axial T1-weighted MR images (left and center) demonstrating nonenhancing interhemispheric and left premesencephalic cysts. Midsagittal T1-weighted MR image demonstrating the extent of the NCC cyst.

Case 2. Postventriculostomy CT scans revealing a right quadrigeminal cyst that extends into the atrium of the right lateral ventricle.

Case 3. Left and Center: Axial MR images with and without gadolinium demonstrating a ring-enhancing lesion at the foramen of Monro. Right: Postgadolinium coronal MR image was better at demonstrating the cyst localized to the third ventricular vellum.

In two patients (Cases 1 and 2), multiple thin-walled, ballottable cysts were encountered. The cysts were torn when a transendoscopic instrument was used to grasp them. This allowed evacuation of the largest cysts and subtotal removal of a few of the smaller cysts that had been inaccessible. In Case 1, small cysts encountered behind (from the endoscopic perspective) the anterior cerebral vessels could not be completely removed. As with intraventricular cysts[8,9] the lesions were removed by withdrawing the endoscope instead of attempting to pull the cyst through the small instrumentation channel of the endoscope.

In Case 3, the cyst within the velum interpositum (tela choroidea of the third ventricle) (Video 3) was approached using two frontal burr holes for a two-port technique. Unlike the other two cases, this cyst showed a thick ring enhancement on gadolinium-enhanced MR imaging. A rigid-lens 30 angled endoscope was passed through one port and standard microsurgical instrumentation passed through a No. 14 F peel-away sheath via the other port. The cyst was quite thick walled, which allowed for gross-total removal.

No surgery-related complications resulting from endoscopic resection occurred. In the event of minor bleeding, continuous irrigation was effective in achieving hemostasis within minutes. In two of three patients (Cases 1 and 3), VP shunts were inserted. In one patient, who was returned to the operating room after resolution of meningitis, a CSF shunt was placed after he could not be weaned from external drainage. Based on the findings of CSF within the fourth ventricle and cisterna magna, a CSF shunt was placed in the other patient (Case 2).

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