Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 5, 2010, pp. 814-815

Neurology India, Vol. 58, No. 5, September-October, 2010, pp. 814-815

Letter to Editor

An unusual cause of entrapment of temporal horn: Neurocysticercosis

Sunil K Singh¹, Chhitij Srivastava¹, BK Ojha¹, Anil Chandra¹, Anit Parihar², Nuzhat Husain³

¹ Department of Neurosurgery, CSM Medical University, Lucknow - 226 003, India
² Department of Radio-diagnosis, CSM Medical University, Lucknow - 226 003, India
³ Department of Pathology, CSM Medical University, Lucknow - 226 003, India

Correspondence Address:
Sunil K Singh
Department of Neurosurgery, CSM Medical University, Lucknow - 226 003
India
drsksingh2k@gmail.com

Date of Acceptance: 29-Jul-2010

Code Number: ni10235

PMID: 21045533

DOI: 10.4103/0028-3886.72204

Sir,

Entrapment of temporal horn is a rare entity caused by obstruction at the trigone of the lateral ventricle, which seals off the temporal horn from the rest of the ventricular system. ^[1] Intraventricular cysticercosis accounts for 7% to 30% of NCC ^[2] and it causing an entrapped temporal horn has not been reported till date. We are reporting two interesting cases of entrapped temporal horn syndrome caused by giant intraventricular cysticercosis.

Case 1: A 35-year-old woman presented with a 4-day history of headache and vomiting. Computerized tomography (CT) scan showed a large right temporal cystic lesion with a few intra-cystic and parenchymal micro calcifications. Contrast magnetic resonance imaging (MRI) showed multiple large cysts in the right temporal horn. Patient was taken up for surgery and the temporal horn was approached endoscopically. Multiple cysts were removed and a stoma was made to connect with the ipsilateral atrium; but later, shunt surgery was required. There were no further complications during 1-year of follow-up.

Case 2: A 35-year-old woman presented with two months history of headache and left-sided focal seizures. On examination, the Glasgow coma scale score was E3V3M5. Contrast CT scan brain showed a non-enhancing right temporal cystic mass. Contrast MRI showed a huge 6-cm T1 hypointense and T2 hyperintense lesion. The patient was taken up for emergency surgery. The cyst was aspirated, yielding a lightly viscous straw-colored fluid. The lesion was approached through a trans-sulcal route until a well-defined whitish translucent cyst wall was encountered. The fluid earlier aspirated was actually from the entrapped horn as the cyst itself contained only clear fluid. The cyst was removed in toto without rupture and was found to contain multiple similar small cysts inside it measuring about 5 cm in diameter.

Microscopically the typical cysticercus cyst wall was seen in both the cases. The lesion showed areas of degeneration, including the scolex. The large cysts also contained multiple daughter cysts [Figure - 1]. On follow-up CT scans, the size of the temporal horn had significantly reduced in both patients [Figure - 2] Entrapment of the temporal horn is the term first used by Maurice-Williams et al. to describe a form of focal hydrocephalus. Temporal horn contains choroid plexus, and the cerebrospinal fluid secreted results in the temporal horn expansion into a cyst. This results in symptoms of raised intracranial pressure and focal deficits. ^[3] Causes of entrapped temporal horn include tuberculous choroids plexitis, streptococcal choroid plexitis, hydatid cyst, recurrent glioma, postsurgical removal of arterio venous malformation, pseudomonas, neurosarcoidosis, histiocytosis and cryptococcal meningoencephalitis. ^[3]

Probably these two patients are the first documented cases of entrapped temporal horn caused by a giant neurocysticercus. Neurocysticerci undergo four stages of involution: vesicular, colloidal, granulovacuvolar and calcific. This evolution does not occur in the intraventricular or the subarachnoid forms (or racemose type) of NCC. ^[4] Degenerating cyst can elicit a widespread ependymitis. However, this pathological process has never been known to cause entrapment of a part of the ventricular system.

The treatment of IV NCC is symptom specific. Antihelminthic medication, albendazole or praziquantel, hastens the evolution of intraventricular viable cysts, which may trigger an inflammatory response similar to that seen with the natural history of the parasite. This may result in long-term sequelae. It is a common practice to ascribe entrapment of the temporal horn to tubercular meningitis in developing countries and treat empirically by shunting and anti-tubercular therapy. However, this previously unknown cause of the entrapped horn, NCC must be kept in mind, especially in the developing world whenever planning shunting of an entrapped temporal horn as the primary therapy. An enhanced MRI scan should be done to exclude other causes especially cysticercosis.

References

1.	Watanabe T, Katayama Y. Evaluation by magnetic resonance imaging of the entrapped temporal horn syndrome. J Neurol Neurosurg Psychiatry 1999;66:113.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.	Suri A, Goel RK, Ahmad FU, Vellimana AK, Sharma BS, Mahapatra AK. Transventricular, transaqueductal scope-in-scope endoscopic excision of fourth ventricular neurocysticercosis: A series of 13 cases and a review. J Neurosurg Pediatrics 2008;1:35-9.  Back to cited text no. 2
3.	Maurya P, Singh VP, Prasad R, Bhaikhel KS, Sharma V, Kumar M. Intraventricular hydatid cyst causing entrapped temporal horn syndrome: A case report and review of literature. J Pediatr Neurosci 2007;2:20-2.  Back to cited text no. 3
4.	Palacios E, Carbajal RJ, Taveras JM. Cysticercosis of the Central Nervous System: The Pathology of Neurocysticercosis. Springfield: Charles C Thomas Pub Ltd.; 1983.p.27-54.  Back to cited text no. 4

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