(Stroke. 1998;29:123-125.)
© 1998 American Heart Association, Inc.
Frequency of Cerebral Arteritis in Subarachnoid Cysticercosis
An Angiographic Study
Fernando Barinagarrementeria, MD;
Carlos Cantú, MD
From the Stroke Clinic, Instituto Nacional de Neurología y
Neurocirugía, Mexico City, Mexico.
Correspondence to Fernando Barinagarrementeria, MD, Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía, Manuel Velasco Suárez, Insurgentes Sur 3877, Tlalpan 41269, Mexico City, Mexico
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Abstract
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Background and
Purpose—Subarachnoid cysticercosis is a well-recognized
cause of cerebral infarction. However, few patients with this infection
develop cerebral infarction, and the reason for this is not known. The
aim of this study was to determine the frequency of cerebral arteritis
in these patients.
Methods—Using cerebral arteriography, we studied 28 patients with
subarachnoid cysticercosis admitted to our hospital from July
1993 to February 1996. All patients underwent MRI to detect the
presence of basal arachnoiditis. We analyzed demographic data,
time to cysticercosis since the first symptom onset, mode of onset,
stroke syndromes, neuroimaging features of cysticercosis and cerebral
infarction, and arteriographic findings for each patient.
Results—Of the 28 patients (mean age, 37 years), 15 patients had
angiographic evidence of cerebral arteritis (53%); 12 of the 15 had a
stroke syndrome (P=.02). Eight of the 15 patients (53%)
with cerebral arteritis had evidence of cerebral infarction on MRI,
whereas only one patient without cerebral arteritis had cerebral
infarction (P=.05). The most commonly involved vessels
were the middle cerebral artery and the posterior cerebral artery.
Conclusions—The frequency of cerebral arteritis in
subarachnoid cysticercosis is higher than previously reported,
and middle-size vessel involvement is a common finding, even in those
patients without clinical evidence of cerebral ischemia.
Key Words: arteritis • cerebral infarction • cysticercosis • meningitis
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Introduction
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Cerebrovascular
complications of neurocysticercosis include cerebral infarction,
transient ischemic attacks, and brain
hemorrhage.1 2 The most common mechanisms
by which cysticercosis produces cerebrovascular disease are related to
cerebral arteritis, mainly in patients with subarachnoid
cysticercosis.3 4 Several clinical reports of
cerebral infarction resulting from cysticercosis showed that primarily
small brain vessels are compromised by the
parasite.5 6 A few series studied the role of
cerebral arteriography in the evaluation of patients with
cysticercosis.7 8 9 However, the prevalence of
angiographically documented cerebral arteritis associated with
subarachnoid cysticercosis is unknown. Little is known to date
about the frequency and features of cysticercotic arteritis despite the
high prevalence of cysticercosis in several countries. The goals of the
present study were to determine both the frequency of angiographic
abnormalities in patients with subarachnoid cysticercosis and
the clinical findings in this patient group.
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Subjects and Methods
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Among 1454 consecutive patients admitted to our Neurology
Department from July 1993 to February 1996, 102 consecutive patients
with cerebral cysticercosis were evaluated. Forty-nine patients with
subarachnoid cysticercosis were selected to undergo four-vessel
arteriography. Twenty-eight patients provided informed consent and
underwent cerebral arteriography.
All patients met the following diagnostic criteria for
subarachnoid cysticercosis: a positive immunologic reaction to
cysticerci in cerebrospinal fluid and MRI consistent with
definitive evidence of cysticerci cysts in the subarachnoid
space.
In each case, demographic data, the time to cysticercosis since the
first symptom of cysticercosis onset, risk factors, mode of onset,
stroke syndromes, neuroimaging features of cysticercosis and cerebral
infarction, and arteriographic findings were analyzed.
The mode of onset was defined as vascular when the presenting
complaints resulting from cysticercosis were related to a
symptomatic cerebral infarction or transient
ischemic attack, and nonvascular when the presenting
complaints of cysticercosis were related to seizures, intracranial
hypertension, chronic meningitis, a progressive focal neurological
deficit, and mental disorders including dementia and psychiatric
disturbances. Acute onset was considered when symptoms appeared
suddenly or developed in less than 48 hours.
The following stroke syndromes were considered: (1)
symptomatic cerebral infarction, defined as rapidly
developing focal loss of cerebral function with symptoms and signs
lasting more than 24 hours10 that was associated
with a corresponding area on MRI; (2) silent cerebral infarction,
defined as an asymptomatic ischemic brain lesion
disclosed by neuroimaging studies11 ; and (3)
transient ischemic attack, defined as an acute focal
neurological deficit from ischemic origin that lasted less than
24 hours.12
In all patients, an MRI scan was performed with gadolinium enhancement.
The following cysticercosis neuroimaging features were evaluated: (1)
focal arachnoiditis when there was contrast enhancement in only one
cerebral basal cistern; (2) diffuse arachnoiditis, in which contrast
enhancement involved several basal cisterns; and (3) cerebral
infarction, in which the number and location of cerebral infarctions
were analyzed and classified as superficial, deep nonlacunar
(>20 mm), and deep lacunar. In each case with cerebral
infarctions, the close relation with a neighboring subarachnoid
cysticercus cyst was evaluated.
Four-vessel cerebral arteriography using the technique of Seldinger was
performed in all patients. The arteriographic criteria for diagnosis of
cerebral arteritis included segmental narrowing, a beaded appearance of
the cerebral vessels, and abrupt or tapered areas of vascular
obstruction.13 14
Demographic, clinical, and neuroimaging features were analyzed
in accordance with the presence of arteriographic abnormalities (group
A) or normal findings (group B). The differences between the groups
were evaluated for statistical significance with the use of the
2 test and Fisher's exact test.
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Results
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We studied 28 patients, 19 males (68%) and 9 females (32%), who
had a mean age of 37 years (range, 16 to 58 years). Risk factors
included tobacco and alcohol use in 3 each (11%), diabetes mellitus in
2 (7%), and arterial hypertension in 1 (4%).
Fifteen of the 28 patients (53%) had arteriographic evidence of
cerebral arteritis; their demographic and clinical data compared with
those patients without arteritis are shown in Table 1
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Table 1. Demographic Data and Clinical Features of
Patients With (Group A) and Without (Group B) Cerebral Arteritis
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A stroke syndrome was found in 80% of patients with cerebral arteritis
(P=.02). None of these patients had a history of
cerebrovascular disease. Vascular onset as the first manifestation of
cerebral cysticercosis was more common in patients with cerebral
arteritis than in those without. In 20% of patients with cerebral
arteritis, this finding was asymptomatic
(Figure).
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Figure 1. A, T1-weighted MRI shows a basal cysticercus (large arrow) in
peduncular cistern. B, Cerebral arteriography, vertebrobasilar
territory, anteroposterior view discloses a long, narrow segment of the
left posterior cerebral artery (small artery).
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Regarding the frequency of cerebral infarction demonstrated by MRI, 8
of 15 patients (53%) with cerebral arteritis had evidence of cerebral
infarction, whereas only one patient without cerebral arteritis (7%)
had evidence of cerebral infarction (P=.05). The
characteristics of cerebral infarctions are shown in Table 2.
Cerebral arteritis was angiographically documented in 30 vessels in 15
patients. The most commonly affected vessels were the middle cerebral
artery and the posterior cerebral artery, which were involved in more
than half of the patients. The numbers of affected vessels were as
follows: one vessel in 8 patients (53%), two vessels in 4 (26%), and
three, five, and six vessels in 1 patient each (6%). Among 7 patients
with multiple-vessel involvement, 5 of them (71%) had diffuse
arachnoiditis; only 3 of 8 patients (37%) with one-vessel involvement
had diffuse arachnoiditis.
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Discussion
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Angiographically documented cerebral arteritis has been poorly
demonstrated. The first angiographic study of cysticercosis was
performed by Moniz et al,15 who reported two
patients with arteritis at the level of the internal carotid artery.
Lombardo and Mateos7 described the angiographic
findings in seven patients with cysticercosis and reported only
elongation of the pericallosal artery resulting from hydrocephalus,
with no mention of cerebral arteritis. After studying eight patients,
Santín and Vargas8 concluded that
cerebral arteriography is not useful in cerebral cysticercosis. Rocca
and Monteagudo9 reported angiographic
abnormalities in 23 of 46 patients (50%) with cysticercosis.
Cysticercosis was not described in detail in any of those studies. In
the last few years, several case reports of cerebral infarction related
to cysticercosis have been published, few of them with angiographic
abnormalities.16 17 18 19 20 21
The frequency of symptomatic cerebral arteritis in patients
with cysticercosis is not well known. In pathological studies, the
presence of endarteritis in the vessels located in the vicinity of the
parasite is a well-recognized phenomenon.4 The
frequency of cerebral infarction related to cysticercotic arteritis
varies in published series between 2% and
12%.4 5 16 17 18 19 20 21 In the present series, 53%
of all patients with subarachnoid cysticercosis had
angiographically documented cerebral arteritis, most of them
symptomatic (80%). Interestingly, one in five patients
with subarachnoid cysticercosis could have
asymptomatic cerebral arteritis. The natural history of
this form of arteritis is not known. Otherwise, 15% of those patients
without evidence of cerebral arteritis after cerebral arteriography had
a stroke syndrome, probably the result of small-vessel involvement, as
has been previously recognized.5
In the present study the major involved vessels corresponded with
the major intracranial arteries, mainly the middle cerebral artery, as
has been reported in seven of 13
cases.5 16 17 18 19 20 21 22 23
In conclusion, our study demonstrates a high frequency of cerebral
arteritis in patients with subarachnoid cysticercosis and a
close relation between arteritis and the presence of cerebral
ischemia (definite or transient). The distribution of cerebral
ischemic lesions is mainly in the deep portion of the brain and
results from the involvement of medium-size arteries. The recognition
of this complication could modify conventional therapy to prevent
cerebrovascular complications, which increase the morbidity and
mortality in this disease.
Received August 20, 1997;
revision received October 10, 1997;
accepted October 23, 1997.
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Abstract
Introduction
