Atypical Hemorrhagic Presentation of Neurocysticercosis in a Patient on Chronic Anticoagulation

Neurocysticercosis (NCC) is a common parasitic infection of the central nervous system in individuals from endemic regions, but hemorrhagic presentations are rare and may closely mimic neoplastic or vascular lesions, particularly in anticoagulated patients. We describe the case of a 68-year-old woman with a mechanical aortic valve on chronic warfarin therapy who presented with acute confusion and was found to have a left frontal intraparenchymal hemorrhage. Neuroimaging demonstrated a hemorrhagic cystic lesion with an eccentric intracystic nodule suggestive of a scolex, raising concern for NCC despite negative serologic testing. Because serologic assays have limited sensitivity in solitary parenchymal disease, the diagnosis was approached with uncertainty and relied on the characteristic MRI appearance, epidemiologic risk, and the lesion's progressive radiologic regression on follow-up imaging. Management included reversal and temporary suspension of anticoagulation, initiation of albendazole with corticosteroids, seizure prophylaxis, and treatment of hyponatremia, partially pseudohyponatremic due to hyperglycemia but ultimately consistent with syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient showed gradual clinical improvement and near-complete radiologic resolution over several months. This case underscores the diagnostic challenges of hemorrhagic NCC, the limited sensitivity of serologic assays in solitary parenchymal lesions, and the potential for anticoagulation to amplify hemorrhagic complications. It also highlights the essential role of serial neuroimaging and multidisciplinary management in guiding therapy and avoiding unnecessary surgical intervention.