Clinical Review & Education
Images in Neurology
Papilledema From Intraventricular Neurocysticercosis Laura C. Huang, BA; Jayanth Sridhar, MD
A woman in her 30s presented with a 3-month history of bilateral blurry vision with transient visual obscurations and a 1-month history of tinnitus. Funduscopic examination findings were concerning for bilateral optic disc edema, which was worse in the right eye compared with the left (Figure 1). Magnetic resonance imaging of the brain demonstrated multiple cysts in the posterior fossa, including a large cyst inducing obstructive hydrocephalus at the level of the fourth ventricle measuring 1.2 cm × 1.6 cm in anteroposterior and transverse dimensions (Figure 2). She underwent emergent suboccipital craniotomy with removal of the cysts and placement of a temporary external ventricular catheter. Cerebrospinal fluid analysis results revealed no protein, white blood cells, or organisms. Surgical pathology con-
firmed the diagnosis of neurocysticercosis. The patient was treated for 14 days with 400 mg twice daily of albendazole by mouth along with intravenous dexamethasone, 2 mg, twice daily followed by a rapid oral corticosteroid taper. Follow-up cerebrospinal fluid analysis results revealed rare white blood cells, no protein, and no organisms. Two months later, the patient presented with continued blurry vision and bilateral sixth nerve palsies and required ventriculoperitoneal shunt placement owing to a communicating hydrocephalus. At follow-up, the patient had resolution of all visual symptoms. Follow-up magnetic resonance imaging demonstrated reduction in size of the culprit cyst to 0.5 cm × 0.8 cm in anteroposterior and transverse dimensions.
Discussion Figure 1. Fundus Photography at Time of Presentation A Right eye
Intraventricular cysticercosis can cause visual loss due to papilledema and associated optic neuropathy. Continued visual loss due to a communicating hydrocephalus following treatment of neurocysticercosis is attributed to inflammation induced by parasite death.1
Figure 2. Magnetic Resonance Imaging at Time of Presentation
B Left eye
A, Fundus photograph of the right eye depicts florid optic nerve edema with disc hemorrhages and exudates. B, Fundus photograph of the left eye depicts a similar, less severe presentation.
ARTICLE INFORMATION Author Affiliations: Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida.
Magnetic resonance imaging of the brain demonstrates a large cyst inducing obstructive hydrocephalus at the level of the fourth ventricle (arrowhead).
Corresponding Author: Jayanth Sridhar, MD, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17th St, Miami, FL 33136 ([email protected]). Accepted for Publication: February 26, 2015. Published Online: May 26, 2015. doi:10.1001/jamaneurol.2015.0470.
jamaneurology.com
Conflict of Interest Disclosures: None reported. REFERENCE 1. Jiménez-Vázquez OH, Nagore N. Endoscopic evidence of ventricular and cisternal inflammatory changes after intraoperative cysticercal rupture during endoscopic third-ventriculostomy removal. Br J Neurosurg. 2013;27(1):137-138.
(Reprinted) JAMA Neurology Published online May 26, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/29/2015
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Images in Neurology
Papilledema From Intraventricular Neurocysticercosis Laura C. Huang, BA; Jayanth Sridhar, MD
A woman in her 30s presented with a 3-month history of bilateral blurry vision with transient visual obscurations and a 1-month history of tinnitus. Funduscopic examination findings were concerning for bilateral optic disc edema, which was worse in the right eye compared with the left (Figure 1). Magnetic resonance imaging of the brain demonstrated multiple cysts in the posterior fossa, including a large cyst inducing obstructive hydrocephalus at the level of the fourth ventricle measuring 1.2 cm × 1.6 cm in anteroposterior and transverse dimensions (Figure 2). She underwent emergent suboccipital craniotomy with removal of the cysts and placement of a temporary external ventricular catheter. Cerebrospinal fluid analysis results revealed no protein, white blood cells, or organisms. Surgical pathology con-
firmed the diagnosis of neurocysticercosis. The patient was treated for 14 days with 400 mg twice daily of albendazole by mouth along with intravenous dexamethasone, 2 mg, twice daily followed by a rapid oral corticosteroid taper. Follow-up cerebrospinal fluid analysis results revealed rare white blood cells, no protein, and no organisms. Two months later, the patient presented with continued blurry vision and bilateral sixth nerve palsies and required ventriculoperitoneal shunt placement owing to a communicating hydrocephalus. At follow-up, the patient had resolution of all visual symptoms. Follow-up magnetic resonance imaging demonstrated reduction in size of the culprit cyst to 0.5 cm × 0.8 cm in anteroposterior and transverse dimensions.
Discussion Figure 1. Fundus Photography at Time of Presentation A Right eye
Intraventricular cysticercosis can cause visual loss due to papilledema and associated optic neuropathy. Continued visual loss due to a communicating hydrocephalus following treatment of neurocysticercosis is attributed to inflammation induced by parasite death.1
Figure 2. Magnetic Resonance Imaging at Time of Presentation
B Left eye
A, Fundus photograph of the right eye depicts florid optic nerve edema with disc hemorrhages and exudates. B, Fundus photograph of the left eye depicts a similar, less severe presentation.
ARTICLE INFORMATION Author Affiliations: Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida.
Magnetic resonance imaging of the brain demonstrates a large cyst inducing obstructive hydrocephalus at the level of the fourth ventricle (arrowhead).
Corresponding Author: Jayanth Sridhar, MD, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17th St, Miami, FL 33136 ([email protected]). Accepted for Publication: February 26, 2015. Published Online: May 26, 2015. doi:10.1001/jamaneurol.2015.0470.
jamaneurology.com
Conflict of Interest Disclosures: None reported. REFERENCE 1. Jiménez-Vázquez OH, Nagore N. Endoscopic evidence of ventricular and cisternal inflammatory changes after intraoperative cysticercal rupture during endoscopic third-ventriculostomy removal. Br J Neurosurg. 2013;27(1):137-138.
(Reprinted) JAMA Neurology Published online May 26, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/29/2015
E1
