Neurocysticercosis: diagnostic dilemma

Initial contrast computed tomographic brain showed two subcentimetre (7 mm and 9 mm) left parieto-occipital adjacent rim-enhancing lesions (Fig a) with T1-weighted hypointense and T2-weighted/fluid-attenuated inversion recovery hyperintense signal on contrast magnetic resonance imaging (MRI) [Fig b]. Figure. (a) (i) Axial and (ii) coronal reformatted contrast computed tomography showing two rim-enhancing lesions over left parieto-occipital region (arrows). (b) (i) Magnetic resonance (MR) axial images showing T1-weighted (T1W) hypointense and T2-weighted (T2W) hyperintense lesions over left parieto-occipital region with perifocal oedema (arrows); (ii) post-gadolinium T1W MR axial and coronal images showing rim enhancement of the lesions (arrows). (c) Single-voxel MR spectroscopy of left parieto-occipital lobe lesion of (i) short (TE 30), (ii) intermediate (TE 135), and (iii) long (TE 270) echo showing significantly elevated lipid-lactate (1.3 ppm), with a peak doublet centred at 1.3 ppm in TE 30 and TE 270, and inverts in TE 135; N-acetylaspartate peak (2.0 ppm) is decreased; and choline (3.2 ppm) is not elevated. (d) Perfusion imaging in arterial spine labelling showing no significantly elevated regional cerebral blood flow over the left parieto-occipital lesions. (e) T2W and post-gadolinium T1W MR axial images at (i) 2-month and (ii) 5-month intervals showing gradual reduction in the size of the two rim-enhancing lesions over parieto-occipital region (arrows) Subsequent extensive investigations of blood (including anti-Taenia solium immunoglobulin G), CSF, urine and stool for tuberculosis and T soliumwere performed, and all results were negative. Attempts have been made in the literature to distinguish cysticercosis and tuberculosis neurological infection by combined interpretation of the clinical, radiological, and serological features.2 3 4 Clinically, tuberculomas are more often associated with increased intracranial pressure and focal neurological deficits, whereas patients with neurocysticercosis are usually less symptomatic or present with seizures.2 Radiologically, the imaging findings of neurocysticercosis are variable, depending on the stage and location of infestation.