Acta Neurochir (Wien) (2007) 149: 341346

DOI 10.1007/s00701-006-1059-z
Printed in The Netherlands
Clinical Article
Neuro-endoscopic management of intraventricular
neurocysticercosis (NCC)
M. Husain
1
, D. K. Jha
2
, M. Rastogi
1
, N. Husain
3
, and R. K. Gupta
4
1
Department of Neurosurgery, King Georges Medical University, Lucknow, India
2
Department of Neurosurgery, St. Stephens Hospital, Tishazari, Delhi, India
3
Department of Pathology, King Georges Medical University, Lucknow, India
4
Department of Radiodiagnosis, Sanjai Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India
Received April 20, 2006; accepted October 5, 2006; published online March 8, 2007
# Springer-Verlag 2007
Summary
Objective. Various approaches including endoscopy
have been used for the treatment of intraventricular and
cisternal NCC. We present our technique of Neuro-endo-
scopic management of intraventricular NCC.
Methods. Twenty-one cases, 13 females and 8 males
(age range 1250 years; mean, 25.7 years), of intraven-
tricular NCC [lateral (n 6), third (n 6), fourth (n 10)
ventricles including a patient with both lateral and third
ventricular cysts] producing obstructive hydrocephalus
formed the group of study. Gaab Universal Endoscope
System along with 4 mm 0

and 30

rigid telescopes were

used through a frontal burr-hole for removal of intraven-
tricular including intra-fourth ventricular (n 10) NCC.
Endoscopic third ventriculostomy (ETV) was done for
internal cerebrospinal uid (CSF) diversion. Average fol-
low up was 18 months.
Results. Complete (n 18) or partial (n 2) removal
of NCC was done in 20 patients, while a cyst located at
foramen of Monro slipped and migrated to occipital or
temporal horn in 1 patient. Thirty-degree 4-mm rigid
telescope provided excellent image quality with ability
to address even intra-fourth ventricular NCC through the
dilated aqueduct using a curved tip catheter. No patient
required further surgery for their hydrocephalus. There
was no operative complication and post-operative ven-
triculitis was not seen in any case despite partial removal
of NCC.
Conclusion. Neuro-endoscopic surgery is an effective
treatment modality for patients with intraventricular
NCC. It effectively restores CSF ow and is capable of
removing cysts completely or partially from accessible
locations causing mass effect. Partial removal or rupture
of the cyst does not affect the clinical outcome of the
patients.
Keywords: Cisternal; intraventricular; neurocysticer-
cosis; neuroendoscopic.
Introduction
Intraventricular or cisternal NCC is seen in 1233%
of neurocysticercosis [9, 10, 19, 23]. Its prognosis is
poorer than that for parenchymal NCC, making prompt
diagnosis and treatment especially important [10, 22, 32].
Intraventricular cyst can cause obstructive hydrocepha-
lus, due to its larger size and more so if it is located in
third or fourth ventricle, onset of which is frequently
abrupt. Treatment options are medical, external shunt, mi-
crosurgery or endoscopic surgery alone or in combina-
tions; however external shunt and microsurgery are the
commonest mode of treatment used and there is no con-
sensus as regard to the ideal treatment [2, 18, 22, 24, 26].
Microsurgery for cyst removal needs craniotomy, more
brain invasion=retraction, increased operative time and
blood loss. In addition, CSF diversion in the form of
external shunt is usually needed. Shunts are prone to
complications in these patients. Endoscopic techniques
have been found to be effective in intraventricular NCC
[1, 3, 4, 7, 16, 27, 33]; however there are rare reports
of intra-fourth ventricular NCC treated endoscopically
[1, 3, 16, 33].
We present our experience of neuro-endoscopic man-
agement of intraventricular including intra-fourth ventric-
ular NCC during the last 6 years at the Department of
Neurosurgery, KGMU, Lucknow, India. This is the larg-
est series to date with regard to the neuro-endoscopic
treatment of patients of NCC with hydrocephalus.
Material and methods
Twenty-one patients of intraventricular (n 18), in-
traventricular with parenchymal (n 2) and intraventric-
ular with pre-pontine=suprasellar cisternal (n 1) NCC
presenting with obstructive hydrocephalus, treated by
neuro-endoscopic technique during the last 6 years,
formed the group for study. Patient characteristics and
location of NCC are summarized in Table 1. Locations
of the cyst=s included lateral ventricle (n 6), third
ventricle (n 6) and fourth ventricle (n 10) including
a patient with cysts in both lateral and third ventricles
(Fig. 2a and b). There were 13 females and 8 males with
age range 1250 years (average 25.7 years). Clinical
characteristics (table) included headache (n 21), vom-
iting (n 13), seizures (n 4), cranial nerve involvement
(n 3), diplopia (n 3), altered level of consciousness
(n 2) diminution of vision (n 4) meningism (n 1),
and upper gaze palsy (n 1) alone or in various combi-
nations. Computed tomography (CT) (n 21), magnetic
resonance imaging (MRI) (n 10) and enzyme-linked im-
munosorbent assay (ELISA) (n 15) of serum were done
in addition to the routine investigations (Fig. 1a and b).
Neuro-endoscopy
Patients were kept supine with head slightly exed and
xed by adhesive tapes on operating table. Aright (n 18)
or left (n 3) pre-coronal burr hole was used for the
Table 1. Patients characteristics, location of NCC, symptoms and endoscopic managements
C.N. Age Sex Location of NCC Clinical presentation Intervention Cyst removal
1 45 F lateral ventricle headache, vomiting,
altered sensorium
removal of NCC complete
2 31 F lateral ventricle headache, vomiting, ETV, septostomy slipped
3 14 F lateral ventricle headache, vomiting, seizures removal of NCC complete
4 45 F third ventricle
and pre-pontine=
suprasellar cistern
headache, vomiting, meningism,
right third nerve palsy
removal of cisternal NCC
through ETV stoma, ETV
complete
5 30 M fourth ventricle headache, vomiting,
gait abnormality
removal of NCC, ETV complete
6 12 F third ventricle headache, vomiting,
upward gaze palsy
removal of NCC, ETV complete
7. 50 F lateral and third
ventricle
headache, vomiting, diplopia removal of NCC, ETV complete
8 27 M third ventricle headache, seizures removal of NCC, ETV complete
9 17 F fourth ventricle headache, vomiting,
lower cranial nerve palsy
partial removal of NCC, ETV incomplete
10 33 M lateral ventricle headache, diplopia removal of frontal NCC, partial
excision of trigonal NCC
incomplete
11 24 M fourth ventricle headache, seizures removal of NCC, ETV complete
12 18 M third ventricle headache, diminished vision removal of NCC, ETV complete
13 22 F fourth ventricle headache, vomiting, diplopia removal of NCC, ETV complete
14 18 F lateral ventricle headache, altered sensorium, right
third nerve palsy (herniation)
removal of NCC, ETV,
septostomy
complete
15 12 F fourth ventricle headache, seizures removal of NCC, ETV complete
16 20 F fourth ventricle headache, vomiting,
diminished vision
removal of NCC, ETV complete
17 12 M fourth ventricle headache, loss of vision removal of NCC, ETV complete
18 15 F third ventricle headache, vomiting removal of NCC, ETV complete
19 18 F fourth ventricle headache, vomiting, removal of NCC, ETV complete
20 45 M fourth ventricle headache, diminished vision removal of NCC, ETV complete
21 32 M fourth ventricle headache, vomiting removal of NCC, ETV complete
C.N. Case number, NCC neurocysticercosis, M male, F female, ETV endoscopic third ventriculostomy.
342 M. Husain et al.
access depending on location of the cyst. The left side
was used in patients whose left lateral ventricle was large
suggesting Monro occlusion. An additional right parietal
burr-hole was used in one patient with trigonal NCC as
well. Gaab Universal Endoscope System (Karl-Storz,
Tuttlingen, Germany) was used in conjunction with rigid
4 mm 0

and 30

telescopes (Aesculap, Germany). Visu-

alization of posterior third ventricle and dilated aqueduct
was aided by 30

telescope. In one patient with clinical

meningism, akes were seen indicative of previous ven-
triculitis, focal ependymal cicatrisation was seen in three
patients; however ventricular ependyma appeared normal
in all other patients. ETV was done as mentioned in our
previous report [16]. In addition to grasping forceps,
scissors and bipolar electrosurgical probes; cut length
of angiographic catheter (58 French) was used to hold
and remove cysts from various locations by applying
negative pressure at the hub of the catheter with a 10ml
syringe [15]. It was also used to deate large cysts
(n 15). For fourth ventricular NCC, the tip of the cath-
eter was given a desired curvature beforehand to help in
negotiating it through the aqueduct. Smaller cysts were
removed intact; larger cysts were deated and collapsed
by inserting the catheter and sucking out their contents.
Collapsed cyst wall was sucked partially into the catheter,
and held by maintaining negative pressure. Most of the
cysts were pulled out through the working channel by
removing the telescope along with the catheter. However
in two patients with large cysts the whole endoscopic
assembly had to be removed along with the cyst held at
its tip. In a patient with secondary aqueductal-posterior
third ventricular stenosis due to a degenerated cysticer-
cus, two cysts in pre-pontine=suprasellar cistern were
removed through the ETV stoma. In two patients the
cyst remained adherent to the brain parenchyma and
after evacuation of its contents, only part of the cyst wall
could be removed. No attempt was made to pull out the
adherent part in order to avoid parenchymal injury. The
residuum was coagulated with the bipolar electroco-
agulator. Continuous irrigation by Ringers solution was
used during the procedure. Endoscopic procedures done
in patients have been summarized in Table 1.
Postoperatively patients were given dexamethasone
12 mg=day, reduced over 1 week and albendazole
(15 mg=kg=day in three divided doses) for 4 weeks.
Preoperative diagnosis of NCC was based on imaging
studies, and=or serumELISA. Diagnosis was conrmed by
histopatholology (n 20) of the removed cyst. Patients
were followed up at 6 weeks, 3 and 6 months and then
at yearly intervals. Repeat CT was done at or before
3 months.
Results
Patients characteristics, location of NCC, symptoms,
endoscopic managements and results with regards to re-
moval of NCC have been summarized in Table 1. ETV
was done in 18 patients. Denite pre-operative diagnosis
was possible in 18 patients. All MRI scans showed cysts
(Fig. 1a and b), while CT scan was suggestive of cysts in
only 11 patients [5, 11, 12, 14, 21, 28]. Two patients had
additional parenchymal cysts in the right frontal lobe
(n 1) and left occipital lobe (n 1). In one patient,
Fig. 1. (a) T2 with contrast axial MR image showing right lateral
ventricular NCC with univentricular hydrocephalus. (b) T1 MR image
coronal view showing third ventricular NCC with hydrocephalus
Neuro-endoscopy for intraventricular NCC 343
who was taken up for ETV with the presumptive diag-
nosis of aqueductal stenosis on the basis of CT, a third
ventricular NCC was encountered only peroperatively
(Fig. 2b). Serum ELISA for NCC was positive in 10 pa-
tients only. Complete removal of NCC was possible in
most patients (n 18). Often the cyst had imsy attach-
ment to the ependyma from which they could be easily
detached with slight pull and rotatory movements. One
patient had a free oating cyst in the third ventricle.
Parts of the cyst wall were left adherent to the brain pa-
renchyma in a patient with fourth ventricular NCC and
in another with a lateral ventricular cyst attached to the
choroid plexus.
Post-operatively all patients were relieved of their
symptoms of raised ICP, however gaze palsy and lower
cranial nerve involvements improved completely gradu-
ally over a period of 26 weeks. Minimal peri-aqueductal
and fornicial contusions due to negotiating the angio-
graphic catheter and working sheath in patients of fourth
ventricular and third ventricular NCC, respectively were
without any sequel. Slight ooze during blunt perforation
of the third ventricular oor and ETV stoma dilatation
stopped itself and serious bleeding was never encoun-
tered. No patient required an external shunt or further
surgery for their NCC or hydrocephalus. Follow up rang-
ed from 3 months to 5 years (average 18 months).
Discussion
Patients with intraventricular cyst present with symp-
toms of raised ICP due to obstruction to CSF pathway
and brain stem compression due to an enlarging cyst.
These cysts may grow to a large size before presenting
symptoms. Out of twenty-one patients included in our
study, surgical extirpation was possible in most cases, a
complete (n 19) or partial (n 2) removal of NCC was
done. None required any further surgery for their hydro-
cephalus. There is ample evidence that external shunts
are prone to complications in such patients and many of
them die due to repeated shunt revisions and ventriculitis
[6, 8, 17, 20, 2931]. Previous reports of endoscopic
treatment of intraventricular NCC include patients treated
by external shunts pre-operatively [1], during the same
sitting and postoperatively after microsurgical excision
of the cyst [25]. There are rare reports where endoscopy
alone was sufcient for all the patients [1, 16, 27].
Unlike previous reports [1, 4, 13, 27], we subjected all
of our patients of third and fourth ventricular NCC
to ETV. The ease of performing ETV makes us feel
that it should be done in all cases of fourth and third
ventricular NCC subjected to endoscopic surgery, be-
cause of the possibility of delayed stenosis of aqueduct
or forth ventricle outlets due to post inammatory scar-
ring leading to hydrocephalus as seen in previous stud-
ies [4, 13].
Previously, the fourth ventricular NCC has been treated
endoscopically through a suboccipital craniotomy [3].
Besides being major surgery, this approach was not ef-
fective with regards to treating hydrocephalus in a sub-
stantial number of patients and they needed external
shunts. We feel that the transventricular-transforaminal
approach restores CSF ow by ETVand at the same time
third ventricular and even the fourth ventricular cyst can
be removed by the transaqueductal route addressing the
problem with a single burr hole, as done by Anandh et al.
and Zymberg et al. [1, 33]. The aqueduct is widened
in patients of fourth ventricular NCC making it safer
to negotiate and retrieve the cyst. Moreover reduction
in the proximal ventricular pressure tends to push the
Fig. 2. (a) Endoscopic image of right lateral ventricular cyst arising from
septum pellucidum near foramen of Monro. (b) Endoscopic image of
the third ventricular cyst visible through the foramen of Monro
344 M. Husain et al.
cyst towards the aqueduct. The use of catheter to blindly
grasp the cyst in the fourth ventricle through the aque-
duct does not produce any signicant trauma.
Mere evacuation of the cyst can alleviate the mass ef-
fect due to the cyst and we share similar experience as
reported by Psarros et al. that despite rupture of the cyst
peroperatively ventriculitis was not seen [27]. However,
in many of our patients we evacuated the cyst content by
aspirating it with a catheter before attempting to remove
it. In the collapsed form the cyst could be easily handled
and retrieved through the working tube. Continuous
irrigation by Ringers solution peroperatively helps in
removing the debris and provides clear vision. Post-
operative lumbar puncture additionally removes the de-
bris and maintains patency of CSF pathways and of the
stoma of ETV.
Biportal endoscopy, used in earlier reports, may ease
surgical manoeuvering at the cost of more invasion,
which we feel is not needed [13]. Internal CSF diversion
by ETValone or with septostomy should sufce in many
of the cases; however excision of the cyst either com-
plete or partial should be attempted if accessible. We had
to leave a cyst as it slipped away from eld of view; the
patient is asymptomatic and shunt-free.
The exible endoscope provides enhanced navigation
at the cost of image quality. Flexible instruments are dif-
cult to manoeuvre and less sturdy than their rigid coun-
terpart. Transaqueductal passage of exible endoscope
provides a better view of the fourth ventricle and the cyst
in-situ, but at the same time it may damage the brain-
stem as the aqueduct is not in view at the same time [1].
The scope in scope technique described by Gaab is safer
in navigating across the aqueduct, where a small diameter
(2.5 mm) exible neurobrescope is introduced through
the working channel of Gaab Universal neuro-endoscope
under vision into the fourth ventricle. The exible scopes
have a very small working channel (1 mm) with small
delicate forceps which are often insufcient to grasp and
retrieve cysts. In patients with fourth ventricular cysts,
the aqueduct dilates, and lowering of uid pressure in
the third ventricles tends to push the cyst towards the
aqueduct. We used 30

telescopes in the third ventricle

and it was possible in four cases of fourth ventricular
NCC to see the dome of the cyst through the aqueduct. A
cut length of 5-french angiographic catheter with a de-
sired curve was introduced through the working channel
and it passed easily through the aqueduct into the fourth
ventricle dome under constant endoscopic vision to avoid
trauma to the aqueduct [15]. With the catheter tip in the
fourth ventricle a gentle negative pressure applied at the
hub of catheter was able to engage and anchor the cyst
even without viewing it.
ETVand transaqueductal endoscopic procedure is as-
sociated with risk of damage to neurovascular structures
and brainstem as reported in previous studies and should
be done by an experienced neuro-endoscopist [1, 4, 27].
We encountered no major bleeding in any patient. Minor
ooze from the ETV stoma stopped on its own. Frequent
passage of angiographic catheter for partial removal of
the fourth ventricular cyst resulted in minimal surface
contusion of the aqueduct at its anterior margin but it did
not inuence the patients recovery and the outcome.
We conclude that neuro-endoscopic surgery is the
modality of choice for the treatment of intraventricular
including intra-fourth ventricular NCC with hydroceph-
alus. It restores CSF ow and often leads to complete
removal of obstructing cysts at accessible locations.
Intra-operative rupture or incomplete removal of the cyst
has no negative sequel on the nal outcome.
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Comment
This is a very clear report on the endoscopic management of intra-
ventricular neurocysticercosis. The authors extensively discuss results,
pitfalls and possible complications. Well presented and the endoscopic
views are of very good quality.
W. Peter Vandertop
Amsterdam
Correspondence: Mazhar Husain, Department of Neurosurgery,
King Georges Medical University, Lucknow 226003, India. e-mail:
mazharhusain@hotmail.com, mazharhusainlucknow@yahoo.com
346 M. Husain et al.: Neuro-endoscopy for intraventricular NCC