A 44-year-old male presented to the emergency department with sudden-onset drowsiness and left-sided hemiparesis, which began 48 h before admission. Suspecting a stroke, a cranial CT with angiography was performed Figure 1, Panel A, revealing multiple cystic lesions in the right Sylvian fissure and left frontal region, accompanied by edema.Figure 1: (a) Initial computed tomography (CT) scan showing moderate edema and cystic lesions in the right sylvian fissure and left frontal lobe. (b) Follow-up CT scan demonstrating increased edema and worsening midline shift. (c and d) Postsurgical brain magnetic resonance imaging (T2 and fluid-attenuated inversion recovery sequences) revealing severe edema and residual cystic lesions in the left frontal lobe.The following day, due to worsening consciousness, a repeat computed tomography showed increased edema and midline shift Figure 1, Panel B. Neurosurgery was consulted, and a right decompressive craniectomy was performed. Intraoperatively, multiple white, grape-like cystic lesions in the right Sylvian fissure consistent with extraparenchymal neurocysticercosis (NCC) were identified and removed for histopathological analysis Figure 2.Figure 2: (a and b) Light microscopy showing racemose cysticercal bodies.Subsequent magnetic resonance imaging revealed residual lesions in the left frontal region on the fast imaging employing steady-state acquisition sequence Figure 1, Panel C and persistent edema on the fluid-attenuated inversion recovery sequence Figure 1, Panel D. Diffusion-weighted imaging sequence did not reveal any abnormal alterations suggestive of stroke. The patient was started on steroids and albendazole (30 mg/kg) with minimal improvement. After weeks of stability, the patient deteriorated due to super-refractory status epilepticus and left sigmoid cerebral venous thrombosis, requiring orotracheal intubation. Given the poor prognosis, the family requested palliative care, and a decision was made to limit therapeutic efforts. NCC, caused by Taenia solium larvae, is endemic in Latin America, Asia, and parts of Africa, notably in China, India, Peru, and Sub-Saharan Africa.1 It presents in two primary forms: intraparenchymal and extraparenchymal. Racemose NCC, an extraparenchymal subtype, is characterized by clusters of cystic lesions arranged in grape-like pattern.2 In this case, the patient’s hyperacute focal neurological symptoms mimicked a stroke but were ultimately attributed to racemose NCC after stroke and vasculitis were ruled out. This form is often associated with inflammation, edema, and mass effect, which worsen when cysts rupture, triggering a severe inflammatory response. Diagnosis requires a high index of suspicion, supported by serology and neuroimaging. Treatment includes antiparasitic therapy (albendazole, praziquantel) and steroids to mitigate inflammation. Administering antiparasitics without steroids risks severe neurological complications due to the inflammatory response triggered by parasite death. The optimal treatment duration remains unclear, with regimens varying from prolonged albendazole courses to high-dose albendazole (30 mg/kg/day) or combination therapy.2 Surgical intervention is crucial in extraparenchymal NCC to reduce parasitic load and improve prognosis. In this case, decompressive craniectomy was necessary to manage edema and intracranial hypertension.2 Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Murrieta-Hernández et al. (Wed,) studied this question.