Endoscopic intervention for the fourth ventricular neurocysticercal cyst: what should be the optimum therapeutic...

Fourth ventricular neurocysticercal cyst (FVNCC) usually presents with acute hydrocephalus, requiring surgery. Though endoscopic intervention is preferable, there is no consensus on the method and/or the extent of endoscopic intervention. We share our experience of endoscopic intervention for FVNCC and propose an algorithm of management.

We reviewed the clinicoradiological details of consecutive patients, who underwent endoscopic intervention for the FVNCC at our institute from 1998 to 2009. Details of cyst excision, endoscopic intervention(s), cerebrospinal fluid (CSF) diversion (internal and external), complications and the outcome were analyzed.

There were 21 patients. Cyst could be totally excised in 13 patients, while two patients had only partial excision of cyst. Excision of cyst could not be done in five patients due to ependymitis/adhesion, intraventricular hemorrhage (IVH) and poor visibility of CSF due to hazy CSF. One patient only underwent endoscopic third ventriculostomy (ETV), as cyst excision was not planned in view of calcified FVNCC. Three patients had only cyst excision, as the sole endoscopic intervention, while 12 patients underwent ETV along with excision. Two patients had symptomatic periaqueductal injury with partial recovery (one each with rigid and flexible scope). The mean available follow-up was 22 months. Shunt was avoided in 90% of patients. All patients who are available for follow-up are asymptomatic, irrespective of the type of endoscopic intervention and extent of cyst excision status.

Relieving the acute symptomatic hydrocephalus by endoscopic internal CSF diversion (ETV) should be the primary therapeutic goal. Cyst excision (partial or total) should be attempted, only where feasible. The rigid scope is safe and satisfactory for the endoscopic intervention for FVNCC.