Abstract
Cyst enlargement with progressive symptoms in spinal intradural Neurocysticercosis (NCC) is an uncommon finding after effective treatment of NCC. Neither imaging nor clinical presentation is sufficient to differentiate a sterile arachnoid cyst from recurrence of NCC. We present a case of symptomatic spinal intradural cyst enlargement 16 years after successful treatment of intracranial and spinal NCC with anti-helminthics.
Keywords: cyst, intradural, neurocysticercosis, spinal
A 64-year-old female with a remote history of successfully treated cerebral and lumbar intradural extramedullary neurocysticercosis (NCC), with stable spinal cysts on multiple surveillance imaging, presented to the emergency department with progressive bilateral lower extremity weakness following by urinary incontinence 16 years after treatment with anti-helminthics. Patient had negative CSF cultures and completely calcified intracranial lesions; however, spinal imaging revealed enlargement of intradural cysts causing compression on nerve roots. (Figure 1) Patient underwent laminectomy and removal of intradural cysts. Post-operatively, patient’s lower extremity weakness and urinary incontinence improved. The histopathological examination of surgical sample represented sterile and benign cystic inclusions without evidence of scolex or active disease. (Figure 2) Lumbar MRI with and without contrast at 6-months follow up showed resolution of cystic structures with improved patency of the thecal sac and decreased mass effect on the nerve roots (Figure 3).
Figure 1.
Lumbar MRI T1 sagittal (A), T2 sagittal (B), FLAIR post contrast sagittal (C), and T2 axial (D) images showed a cystic lesions with compression on nerve roots.
Figure 2.
Hematoxylin-Eosin, magnifications ×4 (A) and ×40 (B) showing the remaining of cyst wall (likely tegmentum).
Figure 3.
Six months post-operative lumbar MRI, T2 weighted sagittal (A) and axial (B), showed resolution of cystic structures.
Symptomatic enlargement of spinal intradural NCC after effective treatment is rare. Chronic inflammation after treatment of NCC can last for years leading to arachnoiditis and thickening of dura with formation of septated cysts. Although inflammatory reactions are the main contributing factors in initial cyst formation, late enlargement of the sterile cystic lesion might be due to the ball-valve mechanism with unequal CSF flow through a small opening in the cyst and CSF entrapment.1,2
Most of the reported spinal NCC cases were either asymptomatic cysts diagnosed on further workup for cerebral NCC or undiagnosed patients who presented with neurological symptoms and imaging findings of spinal NCC. Cyst enlargement or progressive symptoms were often observed during medical treatment or shortly afterward that required surgical cyst resection. 3 To our knowledge this is the first reported case of delayed complications and management from expansion of these sterile cysts.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Mehrnoush Gorjian https://orcid.org/0000-0002-3997-8052
References
- 1.Sklar E, Quencer RM, Green BA, Montalvo BM, Post MJ. 1989, Acquired spinal subarachnoid cysts: evaluation with MR, CT myelography, and intraoperative sonography. AJNR Am J Neuroradiol. 10(5):1097-1104. [PMC free article] [PubMed] [Google Scholar]
- 2.Weng RHK, Chang MC, Feng SW, Wang ST, Liu CL, Chen TH. Progressive growth of arachnoid cysts with cauda equina syndrome after lumbar spine surgery. J Chin Med Assoc. 2013;76(9):527-531. doi: 10.1016/j.jcma.2013.05.011 [DOI] [PubMed] [Google Scholar]
- 3.Pal A, Biswas C, Ghosh T, Deb P. A rare case of recurrence of primary spinal neurocysticercosis mimicking an arachnoid cyst. Asian J Neurosurg. 2014;12(2):250–252. doi: 10.4103/1793-5482.144176 [DOI] [PMC free article] [PubMed] [Google Scholar]