
==== Front
J Neurosurg Case Lessons
J Neurosurg Case Lessons
J Neurosurg Case Lessons
Journal of Neurosurgery: Case Lessons
2694-1902
American Association of Neurological Surgeons

10.3171/CASE24223
CASE24223
InfectionInfectionPainPainSkull-BaseSkull BaseTechniqueTechniqueSurgical-TechniqueSurgical TechniqueCase Lesson
Transclival endoscopic approach for prepontine cistern neurocysticercosis causing trigeminal neuralgia: illustrative case
Lines-Aguilar William W MD 1
García Héctor H MD, PhD 23
Saavedra Luis J MD 1
Caucha Yelimer MD 1
Heredia Dennis MD 1
Romero Fernando MD 1
Vargas-Urbina John MD 1
Daniel Cuya Cesar MD 1
Lozano Miguel MD 1
Rene Apaza-Tintaya Alejandro MD 1
Mao Vásquez Carlos MD 1
1 Department of Neurosurgery, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
2 Universidad Peruana Cayetano Heredia, Center for Global Health, Lima, Peru
3 Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
Correspondence William W. Lines-Aguilar: Instituto Nacional De Ciencias Neurológicas, Lima, Peru. williamincn@hotmail.com.
INCLUDE WHEN CITING Published September 23, 2024; DOI: 10.3171/CASE24223.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

23 9 2024
23 9 2024
8 13 CASE2422328 3 2024
24 5 2024
© 2024 the authors
2024
the authors
https://creativecommons.org/licenses/by-nc-nd/4.0/ CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

BACKGROUND

Neurocysticercosis (NCC) is a public health problem in most of the world. Approximately 50 million people worldwide experience this disease, and it remains one of the most important causes of neurological morbidity. Extraparenchymal NCC (basal cisterns) is associated with high rates of morbidity and mortality. Currently, minimally invasive approaches, including the endoscopic endonasal approach, are used with good functional results.

OBSERVATIONS

A 25-year-old patient presented with headache and pain in the left hemiface. Magnetic resonance imaging (MRI) showed cystic lesions in the prepontine basal cisterns compressing and displacing the left trigeminal nerve. The cysticercal lesions were excised using a transclival endoscopic approach. There were no complications during surgery, and pathology confirmed the diagnosis of NCC. The pain subsided after surgery. No residual cysts were observed on control MRI.

LESSONS

Minimally invasive approaches can be used to treat tumor and infectious problems of the skull base, as in this case, with good functional results.

https://thejns.org/doi/10.3171/CASE24223

cysticercosis
neurocysticercosis
endoscopic endonasal
subarachnoid neurocysticercosis
transclival approach
Peru
ABBREVIATIONS

FIESTA = fast imaging employing steady-state
MRI = magnetic resonance imaging
NCC = neurocysticercosis.
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pmcNeurocysticercosis (NCC) is an infection of the central nervous system caused by the larval stage of the cestode Taenia solium. NCC is endemic in most countries in Latin America, Africa, and Asia,1–3 with approximately 50 million people experiencing this disease4 and approximately 50,000 people dying of this disease each year. Without aggressive, multidisciplinary, and multimodal treatment, subarachnoid NCC is associated with high rates of morbidity and mortality.5–7 Minimally invasive approaches have been applied as an alternative in the management of subarachnoid NCC. We present the case of a patient with NCC in the prepontine basal cistern that was successfully treated using a transclival endoscopic approach at the National Institute of Neurological Sciences in Lima, Peru.

Illustrative Case

History and Examination

A 25-year-old female patient with no significant prior medical history presented with a 2-month experience of a moderate tointense persistent global headache and intermittent and moderate pain in the left side of the face. The hemifacial pain was described as “electrically stabbing.” No neurological signs were found during the neurological examination. The patient had received carbamazepine 200 mg three times daily with partial improvement of pain. NCC was confirmed by magnetic resonance imaging (MRI) and serum immunoblotting (western blot 5 bands). On MRI (Fig. 1), particularly clear on the fast imaging employing steady-state (FIESTA) sequence, cystic lesions were evident in the prepontine cistern, displacing and elongating the left trigeminal nerve and displacing the basilar artery toward the pons. No other lesions were visible on MRI. Since this was a case of secondary neuralgia, the best approach to control pain was to resolve the lesion that was irritating the trigeminal nerve. Balancing the risks and benefits of excision with those of antiparasitic treatment in which the destruction of the cyst can lead to local inflammation and damage, we chose the surgical approach. We considered the retrosigmoid approach as an alternative; however, with the cysts being very medial and considering the patient’s favorable anatomy (sellar-type sphenoid sinus and thin middle clivus), we chose an endoscopic endonasal approach. FIG. 1. Gadolinium-enhanced MRI. A and B:FIESTA sequences demonstrating cystic lesions in the prepontine cistern (yellow arrows) with elongation of the trigeminal nerve (red arrow). C:Widened prepontine space with slight pontine compression of the pons and medial cerebellar peduncle. D:Left basilar artery displaced toward the right.

Operation

A 0°, 4-mm, 18-cm straight rigid endoscope was used for a transclival endoscopic approach to the middle third of the clivus (Fig. 2). A right nasoseptal flap and a left reverse nasoseptal flap were prepared, and the middle third of the clivus was drilled approximately 1 cm in depth, up to the dura mater, guided by a neuronavigator. A rostrocaudal linear durotomy was then performed. The arachnoid was thickened and difficult to cut. On opening the arachnoid, the NCC cysts were exposed and resected, with subtle traction and irrigation with saline solution. The pretruncal space was explored to rule out the presence of other cysts. Cranial nerves VII, VIII, IX, X, and XI were attached to the petrosal temporal portion. There were no surgical complications. Finally, the surgical area was reconstructed using a dura mater substitute, bone gasket, nasoseptal flap, and fibrin sealant. A lumbar drain was not placed because the patient had a functional ventriculoperitoneal shunt system. The patient’s symptoms improved. There were no postsurgical complications. FIG. 2. A:Initial view after drilling the clivus showing prominences of the carotid artery (ICAp) and sellar floor (S). B: Linear durotomy, thickened arachnoid. C: Exposure of NCC cysts (black arrow) by irrigation with saline. D and E: Resection of cysts (black arrows) with gentle traction. F: Cranial nerves adhered to the petrous temporal portion. G: Arachnoid and free left trigeminal nerve (V). H: Reconstruction with bone gasket (black star). I:Fixation of nasoseptal flap (NSF). BA = basilar artery; C = irrigation cannula.

At the 2-month follow-up, the patient was asymptomatic, and control MRI (Fig. 3) confirmed the absence of NCC cysts in the basal cisterns and the trigeminal nerve in a normal anatomical position. She was referred to the neuroinfectology service for antiparasitic treatment and further follow-up. FIG. 3. Immediate postoperative spiral multislice tomography (A) with a small neumoencephalus in the basal cisterns (yellow arrow), without other findings. Axial FIESTA (Band C)and sagittal postgadolinium T1-weighted (D) MRI 2 months after surgery, confirming the absence of NCC cysts and a trigeminal nerve without evidence of compression and in its normal anatomical position (red arrow).

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

Minimally invasive endoscopic endonasal approaches, designed for the treatment of tumor and inflammatory and infectious entities, allow direct access to skull base pathologies in the midline, with minimal contact with neurovascular structures and avoiding the manipulation of healthy brain tissue.8–12 Kassam and Snyderman and their coauthors introduced an endoscopic approach to the skull base through the sphenoid sinus as a starting point, from which it is possible to reach from the anterior cranial fossa to C2 in a sagittal plane.8–12

Subarachnoid NCC, also called “racemose,” can present with intracranial hypertension, hydrocephalus, meningitis, stroke, or focal neurological symptoms.13, 14 The symptoms in subarachnoid NCC are attributable to mass effects and to the severe inflammatory reactions of blood vessels in the subarachnoid spaces that can cause infarctions of the brainstem and basal nuclei. Most of these cysts are free in the subarachnoid space, which allows easy extraction.15 Large or multiple cysts in the basal subarachnoid spaces (suprasellar cistern or basal cisterns) can generate a great compressive effect on adjacent neurological structures.16 Also, due to different mechanisms, many of these patients develop hydrocephalus, which also requires treatment, usually a ventriculoperitoneal shunt.17 Unlike cystic echinococcosis (hydatid disease), there is no risk of adverse reactions or incidents associated with the intraoperative rupture of cysts.18–20

The treatment of NCC is multidisciplinary and multimodal. Different neurosurgical approaches, including traditional ones (pterional, frontotemporal, suboccipital, etc.), as well as stereotactic and transventricular endoscopic approaches, have been used to resolve the mass effect in different locations.6, 21–23 Two prior cases of endoscopic endonasal approaches for NCC have been reported,13, 15 and both used extended endoscopic approaches toward the sellar tubercle for resection of NCC cysts in the basal cisterns. Trigeminal neuralgia associated with NCC has been treated with conventional approaches (retrosigmoid, pterional).24, 25 Craniotomy with cyst removal is effective in most cases.

In our case, in addition to resecting the cysts, another objective was decompression of the trigeminal nerve that was elongated by the cysts and probably generating the neuralgia. A careful study of a patient’s neuroimages provides the best guidance to select the optimal approach for each patient. In our patient, the sellar-type sphenoid sinus and thin middle clivus favored the transclival endoscopic approach to directly reach the cysts, based on our experience with this type of neuroinfection and the aforementioned reports.13, 15

In the case of intraventricular NCC, standard microsurgical procedures (transcranial approaches) have long been used to remove intraventricular cysts.26–28 Currently, the surgical procedure of choice is the minimally invasive endoscopic approach, especially for ventricular cysts (lateral and third ventricle).18, 29, 30 A similar scenario applies to subarachnoid NCC. Endoscopic surgery avoids the complications of a large craniotomy and reduces the manipulation of healthy brain tissue. The resection of cysts in most cases does not cause major difficulty because the cysts do not adhere to neurovascular structures, which means that with only saline solution irrigation the cysts can be removed without difficulty. In some patients, the cysts adhere densely to surrounding neurovascular structures and may not “deliver” easily. In such a case, the procedure could vary to a more extensive conventional approach.19, 26 A limitation in our approach was the lack of intraoperative navigation equipment, absent at our institution.

Lessons

The endoscopic endonasal approach is an excellent alternative for selected cases of NCC, such as the present case. The resection of cysts and decompression of the trigeminal nerve were achieved without complications, resulting in clinical improvement of the patient.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Lines-Aguilar, Vásquez. Acquisition of data: Lines-Aguilar, Caucha, Vargas-Urbina, Lozano, Apaza-Tintaya. Analysis and interpretation of data: Lines-Aguilar, García, Cuya. Drafting the article: Lines-Aguilar, Saavedra, Heredia. Critically revising the article: Lines-Aguilar, García, Apaza-Tintaya. Reviewed submitted version of manuscript: Lines-Aguilar, Romero, Lozano. Approved the final version of the manuscript on behalf of all authors: Lines-Aguilar. Statistical analysis: Lines-Aguilar. Administrative/technical/material support: Lines-Aguilar, Vargas-Urbina. Study supervision: Lines-Aguilar.

Correspondence

William W. Lines-Aguilar: Instituto Nacional De Ciencias Neurológicas, Lima, Peru. williamincn@hotmail.com.
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