PMC5551286_01
Pre-operative MRI brain with and without contrast was obtained prior to intervention, showing a large left multi-lobulated cystic lesion, causing significant mass effect and midline shift. The cyst contents appears isointense to CSF on MRI imaging. No evidence of enhancement was evident on contrasted imaging. Sequences are as follows: (a) Axial T2 sequence, (b) Axial FLAIR, (c) Axial with contrast, and (d) Coronal with contrast
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F1
The MRI brain, with and without contrast with T2-weighted sequences, revealed high intensity within the cyst, similar to CSF [Figure 1].
Left craniotomy and sylvian fissure dissection is shown. (a) Evagination of the cyst wall with initial sylvian dissection. (b) Gentle traction is applied to the cyst to aid in removal. (c) The cyst ruptures during the process of removal. Copious irrigation was performed to clear cyst contents and the patient was given another dose of dexamethasone. (d) Gross specimen of multi-cystic racemose neurocysticercosis after en bloc resection
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F2
A sylvian dissection was performed, during which the cyst began to evaginate on its own [Figure 2a and b]. Gentle traction was applied to the cyst, which resulted in intra-operative rupture, spilling the cyst contents within the subarachnoid space [Figure 2c]. With completion of the sylvian dissection, the cyst complex was removed en bloc with no intra-operative evidence of residual lesion [Figure 2d].
MRI brain with and without contrast was obtained on post-operative day 1. Residual encephalomalacia is noted in the location previously occupied by the cyst. (a) Axial T2 sequence, (b) Axial flair, (c) Axial with contrast, and (d) Coronal with contrast
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F3
Non-contrast CT head and MRI brain with and without contrast were obtained on post-operative day 1, which showed expected encephalomalacia surrounding the resection cavity, with no evidence of residual lesion [Figure 3].
Surveillance CT head non-contrast was obtained during routine clinic follow-up at 1.5 months post-operation. Imaging shows residual encephalomalacia in the left fronto-temporal lobes, with no evidence or cyst recurrence or enlargement
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F4
Surveillance CT head revealed stable left fronto-temporal encephalomalacia and no evidence of recurrence [Figure 4].
The cuticular layer (black arrow) shows an outer portion with a convoluted appearance of rounded protrusions ("knobs") and microtriches on the surface. The cellular layer (white arrow) is comprised of a syncytium of cell bodies with uniform nuclei. The inner reticular layer contains loosely arranged fibrils, calcifications (arrowheads), as well as excretory canaliculi (asterisks). H & E stain, 400X magnification
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F5
Neuropathology was consistent with neurocysticercosis in racemose cyst formation [Figure 5].