Shikha Bhatia Radiology elective 06/02/17 Case Presentation Shikha Bhatia Radiology elective 06/02/17

J. P. 25 y/o M Presented to Ed C/o persistent headaches over several months Feels dull & in the back of his head with intermittent, sharp neck pain Headaches worse over last week, esp in AM, and associated with dizziness No weight loss, night sweats, GI upset Previously seen in culpepper, dx’ed cervical strain Moved from Honduras 3 years ago Cuts trees for work Pex: No papilledema, Narrow station, Unsteady tandem gait, o/w normal Labs: ↑ lfts, o/w normal

1. Large cystic mass with single area of internal calcification located in the left central posterior fossa causing mild to moderate hydrocephalus, mild transependymal CSF flow, and cerebellar tonsillar herniation.

Differential Large posterior fossa mass in 25 y/o primary brain tumor Pilocytic astrocytoma Medulloblastoma glioblastoma Metastatic brain tumor Cystic lesions Neurocystercircosis Echinococcocis Cystic glioma Pyogenic abscess Tuberculoma Mycotic Granuloma Toxoplasmosis Nocardia

Neurocystercircosis Parasitic disease cause by t. solium, which is endemic in south America, asia, and Africa Weeks to years following ingestion, tissue cysticerci develop in various sites, including the brain Symptoms depend on location – seizures (Intraparencymal) and HA, n/v (subarachnoid) Diagnosis – Imaging most common, but Serology, Fundoscopic exam, Spinal studies and biopsy may also aid Treatment – antiparastics, anti-inflammatories, surgery

Imaging findings Imaging findings vary based on stage of infection Vesicular – cystic, hypodense, round Colloid vesicular – cyst begins to degenerate: cyst wall and cavity increases In intensity, surrounding enhancement 2/2 edema Granular Nodular – Cyst retracts, edema decreases, decreased enhancement Nodular calcified – calcified granuloma, no enhancement Only pathognomonic findings = scolex Elongated, bright nodule within cyst cavity (Fig. B) Enhancing lesions and parenchymal calcifications are also highly suggestive; May also p/w hydrocephalus and leptomeningeal enhancement

What happened? Neurosurgery consulted Suboccipital craniotomy with resection “The wall of the lesion was opened, and a white-colored tendril was unraveled and pulled from inside the cyst” c/b hemorrhage requiring evacuation and aneurysm clipping Uncomplicated recovery following Discharged post-operative day 22 once stable Given baclofen, meclizine, Zofran, and scopolamine patches, with continued rehab

References Gaillard, Frank. "Neurocysticercosis." Radiopaedia. 01 Jan. 2017. Web. 01 June 2017. White AC, Weller PF, and Baron EL. "Clinical Manifestations and Diagnosis of Cystercercosis." UpToDate. 16 DEC 2016. Web. 31 May 2017.

Questions?