Jou rn l of the Koren Rdiologicl Society, 1995 ; 32( 1) : 33-37 MRI of Intrspinl Cysticercosis 1 Seung Cheol Kim, M.D., Kee-Hyun Chng, M.D., Moon Hee Hn M.D., Gi Seok Hn, M.D., HeeYoung Hwng, M.D.2 Purpose ; To describethe MR fetures of intrspinl cysticercosis. Mterils nd Methods ; Medicl records nd MR imges of four cses of intrspinl cysticercosis were retrospectively reviewed. The MR findings were described with regrd to the loction nd signl intensity of the lesions, contrst enhncement, presence or bsence of ssocited intrcrnil cysticerci, nd otherfindings. Results ; There were three cses of subrchnoidl form nd one cse of intrmedullry form. Cysticerci of subrchnoidl form in three cses were locted i n retromedu liry spce t C2 level, nterior to cord t C1 - C6 levels, nd lumboscrl re, respectively. The signl intensities of the lesions were sme s those of CSF. Loclized rchnoidl enhncement wsfound in ll three cses.ln one cse there ws lrge re of high signl intensity within the spinl cord on T2-weighted imge suggesting either ischemi secondry to vsculr compromise or inflmmtory edem. AII of these three cses ccompnied intrcrnil cysticercosis. lntrmedullry cysticercosis in onecse wsshown s single 1 cm cystic lesion t C2 level, which showed hypointense signl on T1 -weighted imge, hyperintense signl on T2-weighted imge, nd signet- ring - like enhncement. This lesion did not ccompny intrcrnil cysticerci. Conclusion; Intrspinl cysticercosis mnifested s single or multiple cysts within either spinl cord or subrchnoid spce, nd were frequently ssocited with rchnoiditis. Index Words; Spinl cnl, MR Spinl cord, infection Prsites INTRODUCTION Intrspinl cysticercosis is extremely rre. There re two forms, intrmedullry nd subrchnoid. Ptients with intrspinl cysticercosis usully present with nonspecific symptoms nd signs including bnormlities of senstion, motor or reflex There hs been only few reports on MR imging of intrspinl cysticercosis (1-4). We describe MR imging findings of spinl cysticercosis in fourcses. 'OeprtmentofRdiology, Seoul Ntionl UniversityCollegeof Med icine 'Oeprtment ofr diology, Ch ung Ang Gil Hospitl Received September 28,1994, Accepted Jnury 13, 1995 Address reprint requests to : Kee -Hyun Chng, M.D., Oeprtment of Rdiology, Seoul Ntionl University Hospit t. '28 Yongon-dong, Chongno-gu, Seoul, 11 0-744 Kore. Tet. 82-2- 760-2519 Fx. 82-2- 743-6385 MATERIALS nd METHODS Four ptients ged from 26 to 63 yers (ll mles) with intrspinl cysticercosis were exmined with MR imging. The dignosis ws proved t surgery nd pthologic exmintion in three cses, while in the re mining one it w9 estblished by the combintion of the imging findir'fgs nd positive serologic tests, enzyme - linked immunosorbent ssy (ELl SA) for cysticercosis - specific immunoglobulin G (Ig G) ntibody MR imges were obtined on 2.0 T (cse 1, 4), 0.35 T (cse 2), or 0.5 T (cse 3) units. AII ptients hd non enhnced sgittl T1 - weighted, x il proton - density weighted, nd T2 - weighted or T2 * - weighted imges Contrst-enhnced T1 - weighted imges were obtin ed fter intrven ous injection of gdopen tette dimeglumin e (0.1 mmol/k g, Mgnevist, Sher ing, Ge r mny) in ll ptients μn
Journl 01 the Koren Rdiologicl Society, 1995 ; 32( 1) : 33-37 MR findings were reviewed regrding to the loction nd signl intensity of the cysts, presence nd pttern of contrst enhncement, nd presence or bsence of ssocited intrcrnil cysticerci. CASE PRESENTATIONS Cse1 A 40 - yer - old mn hd history of right posturiculr pin nd upper extremity wekness for 6 months. There were no other neurologic deficits. On MR imging of cervicl spine there ws 1 cm round cyst within the spinl cord t C2 level. On T1 -weighted imge the lesion showed CSF - like low signl intensity with smll focl iso- signl intensity. On T2 *- weighted xil imge the cystic content of high signl intensity ws outlined by rim of low signl intensity. On postcontrst T1 -weighted imge signetring-like rim enhncement ws found (Fig. 1). There were no bnormlities on the brin MR imging. A totllminectomy ws performed t C2 - C3level. After myelotomy like lesion surrounded by gliotic wll ws found. Pthologiclly the lesion proved to be degenerted cysticercus with gryish necrotic debris. Cse2 A 63 - yer - old mn ws presented with low bck pin of 8 -month history. The symptom ggrvted one week prior to dmission. On dmission he lso complined of hedche nd tremor of right hnd. On neurologic exmintion presthesi of both lower extremities, wekness of right toes, nd decresed deep tendon reflex were detected. Contrst- enhnced T1 - weighted sgittl MR imge of lumbr spine showed m 비 tiple round cysts of low signl intensity with septum - like enhncement of intervening wlls from the level of L 1 to L5 - S1. The lesions showed high signl intensity on T2 - weighted imges. Cud equine were not identifible, being probbly compressed by the multiple cystic lesions (Fig. 2). On brin MR imging there were m 비 tiple cystic lesions in the bse of frontl lobes, suprsellr nd perimesencephlic cisterns, nd posterior foss indicting typicl prenchyml nd cisternl neurocysticercα~is (Fig. 2b). At surgery of lumbr spine, multiple fluid - filled yellowish colored cystic lesions were seen to occupy the thecl sc, which proved to be degenerted cysticerci t mlcroscoplc exmintion. Cse3 A 40 - yer - 이 d mn ws dmitted becuse of wekness of left upper extremity, diplopi nd tingling senstion of extremities for 6 months. Two yers prior to dmission he hd suffered from nuse nd vomiting, nd brin MR imging hd shown multiple cystic lesions in the suprsellr nd sylvin cisterns suggesting meningel cysticercosis nd communicting hydrocephlus. Cervicl spinl MR imging hd shown cystic lesions t the level of the cervicomedullry junction nd medull oblongt He ws dignosed s neurocysticercosis, nd treted with przyquntel. On follow- up MR imging of cervicl spine t dmission there ws 0.76 X 1.5 cm ovoid cyst in the subrchnoid spce posterior to spinl cord tthe level of C2 (Fig. 3). The cyst showed low intensity on T1 - weighted imge nd high intensity on T2 weighted imge. On postcontrst T1 - weighted imge loclized enhncement ws seen on the surfce of slightly enlrged spinl cord. There ws lso lrge re of high signl intensity within the cervicl cord on Fig. 1. Cse 1. T1-weighted (500 /30) sgittl imge 01 cervicl spine shows 1 cm round cyst 01 low signl intensity within spinl cord t C2 level (rrow) b. Postcontrst T1-weighted (500 /30) sgittl imge 01 cervicl spine shows signetring enhncement 01 the lesion (rrow). At surgery, degenerted cysticercus ws removed b - 34
Seung Cheol Kim, et l: MRI of Intrspinl Cysticercosis Fig. 2. Cse 2. Postcontrst T1-weighted (500/30) sgittl imge 01 lumbr spine shows multiple cystic lesions (blck rrows) with locl enhncement 01 multiseptted ppernce (white rrows) occupying entire lumbr durl sc b. On T1-weighted (500 /30) sgittl imge 01 brin there re multiple cystic lesions in right Irontl lobe (rrowhed) nd bsl b F 띠? u C 싫b. On postcontrst T1-weighted (500/30) sgittl imge 01 cervicl spine there is 0.7 X 1.5 cm ovoid lesion 01 low signl intensity (rrow) in re 01 pα, terior portion 01 spinl cord t C21evel. There re multilocl res 01 enhncement on the surlce 01 spinl cord nd inlerior portion 01 the lesion (rrowheds) b. T2-weighted (2500 /90) sgittl imge 01 cervicl spine shows diffuse re 01 high signl intensity within the entire cervicl cord (rrows) suggesting edem secondry to inflmmtion 01 cervicl cord nd/or ischemi/inlrction cused by compromise 01 nterior spinl rtery secondry to cysticercl rchnoiditis c. On postcontrst T1-weighted (500 /30) xil imge 01 brin there re multiple cystic lesions ssocited with cisternl enhncement (rrows) indicting cysticercl meningitis c T2 - weighted imge. Prtil lminectomy of C1 nd totllminectomy ofc2 ws performed. At surgery they found retromedullry cyst in subrchnoid spce with severe dhesion to the surfce of spinl cord, spirted 3 ml of gryish brown colored fluid from the cyst, nd prtilly removed the cyst wl l. Microscopic exmintion of the cyst wll showed some inflmmtory findi ngs suggestive of degenerted cysticercus. Cse4 A 26 - yer - 이 d mn presented with nuse, vomiting, nd hedche. Two yers go he hd been dignosed s neurocysticercosis on the bsis of typicl brin MR findings of cysticercosis nd positive ELl SA test for cysticercus During the follow - up with prziquntel therpy, nuse nd vomiting ws ggrvted, nd tingling senstion of both hnds newly developed. Neurologic exmintion reveled hypesthesi of T2 - T12 35
Journl of the Koren Rdiologicl Society, 1995 ; 32( 1) : 33-37 Fig. 4. Cse 4. Postcontrst T1-weighted (400 /30) sgittl imge of cervicl spine shows tubul r cystic lesion of low signl intensity (rrows) nterior to spinl cord t C1-C6 levels cornpressing the cord posteriorly. There is liner enhncement on the nterior surfce of spinl cord (rrowheds). The cystic lesion presumbly represents either rcemose cysticercus or rchnoid cyst secondry t cysticercl rchnoiditis b. Postcontrst T1-weighted (600/3 0) xl imge of brin shows multiple conglomerted cystic lesions with subtle rim enhncement in right sylvin fissure, suggesting cysticerci of rcemose type (rrows) b dermtome. MR imging of cervicl spine showed n elongted cystlike lesion in the subrchnoid spce nterior to the spinl cord t C1 -C6levels, signl intensity of which ws low on T1 - weighted imge nd high on T2 -weighted imge. The spinl cord ws compressed by the mss. On contrst - enhnced T1 - weighted imge liner enhncement on the nterior s 니 rfce of the spinl cord ws found (Fig. 4). On brin MR imging there were multiple cystic lesions with prtil rim enhncement in the suprsellr cistern, right sylvin fissure (Fig. 4b) nd fourth ventricle, indicting cysticercosis with meningitis. The ptient hs been followed - up with prziquntel tretment with slight improvement ofclinicl symptoms DISCUSSION Although the rdiologic findings of intrcrnil cysticercosis hve been well described (2-12), those of intrspinl cysticercosis hve seldom been reported (1-4, 13), becuse it is n extremely rre form of neurocysticercosis. In study, only one cysticercus out of 106 cysticerci in 50 ptients ws found in spinl subrchnoid spce (4). In nother study by Crbjl et l (8) no spinl cysticercosis ws found mong 232 su rg iclly confi rmed neu rocysticercosi s. Intrspinl cysticercosis involves the subrchnoid spce nd, less often, the cord or epidurl spce (1) The mode of trnsmission of cysticerci to the spinl cnl is by either hemtogenous spred or dissemintion through CSF spce (1, 13). In the present study, three ptients with subrchnoidl cysticercosis hd intrcrnil cysticerci: cisternl (cse 2-4), ventriculr (cse 3), or prenchymllesions (cse 2), wheres one ptient with intrmedullry cysticercosis (cse 1) did not hve intrcrnil lesions. As suggested in our cses, the intrdurl - extrmed 비 lry cysticercosis is likely to be cused by dissemintion through CSF spce, while intrmedullry cysticercα, is my result from hemtogenous spred. The MR findings of cysticercosis re vrible nd depend fundmentlly on four fctors: stges in evolution, loction, size, nd number. Vible cysticerci do not cuse inflmmtion, pper s round cysts with murl nodule (scolex) nd usully show neither enhncement nor edem on MR imging. At this stge the cystic fluid ppers isointense to CSF. After some months to yers, s the cysticerci begin to degenerte, n cute inflmmtory stge my ensue from humorl nd tissue response to cysticerci, cusing surrounding edem nd enhncement on MR imging. Cse 1, intrmedullry form of cysticercosis in the present study, corresponded to this stge which ws confirmed pthologiclly. Spinl subrchnoid cysticercosis presents either s n intrdurl-extrmedullry cyst or s n rchnoiditis (4), for which rcemose cysticercus is presumbly more responsible thn cysticercus cellulose. The rcemose cysticercus is n nomlous, multiloculted form with proliferting bldder wll nd lcking scolex. These cysticerci re usully locted in the ventricles nd bsl cisterns. The rcemose cysticercus within the cisterns my mnifest s lrge spce- occupying lesion of CSF intensity, cusing obstruction or compression of the djcent structures. It frequently incites n extensive leptomengel inflmmtion cusing fibrotic thickening of the surrounding tissue. Chronic grnulomtous meningitis ro 니 nd the bsl cisterns results in communicting hydrocephlus, nd pr이 ifertive endrteritis my cuse infrction (2). Three ptients of subrchnoid form in the present series (cse 2-4) ll showed leptomeningel enhncement on postcontrst MR imging. Surgery confirmed severe inflmmtory dhesion in cse 2 nd 3. Diffuse re of high signl intensity within the entire cervicl cord seen on T2 - weighted imges of cse 3 presumbly represents either edem secondry to inflm- - 36 -
Seung Cheol Kim, et l: MRI of Intrspinl Cysticercosis mtion ofthe spinl cord or ischemi/ infrction cused by compromise of nterior spinl rtery secondry to cysticercl rchnoiditis (Fig. 3b). The cyst ntrior to the spinl cord, s seen in cse 4, might reflect either the rcemose type of cysticercus lck of scolex or rchnoid cyst secondry to dhesive cysticercl rchnoiditis In conclusion, intrspinl cysticercα 히 s mnifested s single or multiple cysts in the subrchnoid spce ssocited with rchnoiditis nd less otten, s solitry cyst with wll enhncement. Contrst enhnced MR imging ppers indispensble in the evlution of ptients suspected of hving rchnoiditis or n intrmedullry lesion with inflmmtion in intrspinl cystícercosí s REFERENCES 1991 ; 1 : 1 59-1 77 4. Zee CS, Segll HD, Boswell W, Ahmdi J, Nelson M, Colletti P MR imging 01 neurocysyicercosis. J Comput Assist Tomogr 1988 ; 1 2 : 927-934 5. Suh DC, Chng KH, Hn MH, Lee SR, Hn MC, Kim Cw. Unusul MR mnilesttions 01 neurocysticercosis. Neurordiology 1989; 31 :396-402 6. Brutto OHD, Zenteno MA, Slgdo P, Sotelo J. MR Imging in Cysticercotic encephlitis. AJNR 1989 ; 1 0 ; 18-20 7. Bi FJ, Brry M. Prsitic inlections 01 centrl nervous systems Neurol Clin 1986 ; 4: 171-206 8. Crbjl JR, Plcios E, Azr KB etl. Rdi 이 gy olcysticercosis 1 the centrl nervous system including computed tomogrphy Rdiology 1977 ; 125 : 127-131 9 김재환, 장기현 l 강익원, 한만청중추신경계유미낭충의방사선학적 고찰대한방사선의학회지 1979 ; 1 5 : 295-302 10. Tsker WG, Plotkin SA. Cerebrl cysticercosis. Peditrics 1979 ; 63: 761-763 11 임덕, 최병인, 홍성모, 장기현뇌낭미충증에대한전산화단층촬영 소견대한방사선의학회지 1983 ; 1 9 : 30-35 1. Cstillo M, Quencer RM, Post MJD. MR 01 intrmedullry spinl 12. Chng KH, Kim WS, Cho SY, Hn MC, Kim Cw. Comprtive cysticercosis. AJNR 1988 ; 9 : 393-395 evlution 01 brin CT nd ELlSA in the dignosis 01 neuro- 2. Chng KH, Lee JH, Hn MH, Hn MC. The role 01 contrst- cysticercosis. AJNR 1988 ; 9: 125-130 enhnced MR imging in the dignosis 01 neurocysticercosis. AJR 1991 ; 157: 509-512 13. Souz LQ, Filho AP, Cllegro 0, DeFri LL. Intrmedullry cysticercosis. Cse report, literture review nd comments on 3. Chng KH, Cho SY, Hesselink JR, Hn MH, Hn MC. Prsitic dis- pthogenesis. JNeurol Sci 1975 ; 26: 61-70 ese 01 the centrl nervous system. Neuroimging Clin North Am 대한방사선의학회지 1995; 32( 1) : 33-37 척추강내유미낭충증의자기공명영상 l l 서울대학교의과대학진단방사선과학교실 2 중앙길병원진단방사선과 김승철 장기현 한문희 한기석 황희영 2 목적척추강내유미남충증의자기공명영상소견을기술하고자한다. 대상및방법 : 척추강내유미낭충증으로증명된 4예의임상경과와자기공명영상소견을후향적으로분석하였다. 자기공명영상소견은병변의위치, 신호강도, 조영증강, 두개강내유미낭충증의유무및기타소견을분석하였다. 결과 : 병변들은지주막하형이 3예, 척수내형이 1 예있었다. 지주막하형의위치는각각제 2경추의척수후방, 제 1-6 경추의척수전방및요천추부위였다. 지주막하병변의신호강도는뇌척수액의그것과같았고, 지주막의국소적조영증강이 3예모두에서있었다. 한예늠 T2 강조영상에서척수내에미만성의고신호강도를보여혈관압박등에의한허혈성변화이 거나혹은염증성부종으로생각되었다. 이들 3 여 모두두개강내유미낭충증을동반하고있었다. 한예의척수내유미낭충증 은제 2경추척수내에 1cm 크기의낭성병변이었다. 이병변은 T1 강조영상에서저신호강도, T2 강조영상에서고신호강도를보였으며병변의주위조영증강을보였다. 이병변은두개강내유미낭충증을동반하지않았다. 결론 : 척추강내유미낭충증은지주막하혹은척수내에단발혹은다발성의낭성병변을동반하며지주막하염과흔히동반된다. -- 4 7
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