Brain, Vol. 124, No. 4, 839-840,
April 2001
© 2001 Oxford University Press
Book reviews |
SOLITARY CYSTICERCUS GRANULOMA:THE DISAPPEARING LESION.
By Vedantam Rajshekhar and Mathew J. Chandy. 2000. London: Sangham Books Ltd. Price £9.95. Pp. 169. ISBN 0-86311-815-1.
Department of Neurology, Morriston Hospital, Swansea, UK
Single small enhancing CT lesions (SSECTLs) are the most common cause of symptomatic epilepsy in the Indian subcontinent. This entity, recognized ever since the introduction of the CT scan in India in the late 1970s, had eluded diagnosis for almost a decade. The stereotactic biopsies of these lesions by the editors proved them to be solitary cysticercus granulomas (SCGs). This monograph deals comprehensively with SCGs, from historical background and clinical presentation, through neuroimaging to management and outcome. All the 13 chapters except one are contributions from C. M. C. Vellore.
The introduction to the subject gives a good description of evolution in the diagnosis of SSECTLs. Many patients with these lesions have been unnecessarily treated with antitubercular therapy as the CT appearances closely mimic tuberculomas. It took a long time to realize that most of SSECTLs are SCGs. One of the important reasons for this delay was the conviction that neurocysticercosis presented with multiple intracranial granulomas rather than with a solitary lesion. By omitting the fact that these lesions were thought to be a postictal phenomenon and were labelled as postictal lesions in the early reports, the authors have not touched upon an important aspect of the history.
The clinical and radiological criteria for the diagnosis of SSECTLs discussed in the book are almost the same as those agreed upon by the Indian neurologists in the national meetings. However, this has not been acknowledged in the bibliography. The epidemiology highlights the studies from the Indian subcontinent and South America where the disease is most prevalent. These studies do not reflect the true picture of the disease as community-based studies are lacking. The authors' belief that most of the cysticercal infection in India is acquired from food consumed outside the home of the patient is not shared by everyone; there are good observations to suggest that food handlers at home may be responsible for passing on the infection to several members of the family.
The chapter on clinical presentation lacks precision and depth. The comment that SCG can be associated with any type of seizures is not appropriate; the disease is not associated with typical absences or myoclonic epilepsy. In addition, theobservation is made that the type of seizures may not necessarily correspond to the location of granuloma (p. 32), as a granuloma in the frontal lobe may be associated with complex partial seizures. This is incorrect as seizures of frontal lobe origin are well known to manifest as complex partial seizures. Enlarging cysticercal granuloma is seen in 3% of all cases of SCGs. The editors discuss this entity based on their personal experience of 13 cases; it has significant implications in the management of SCGs as these cases can be easily confused with tuberculomas and wrongly started on antitubercular therapy.
The best-written chapter is the one on neuroimaging, which gives a detailed CT and MRI description of SSECTLs, supported by good illustrations. There is a comparison of MRI and CT in the management of SCGs. One of the important differential diagnoses of these lesions is a tuberculoma; the radiological features, which differentiate a tuberculoma from SCG, are well discussed. It also describes validation of clinical and diagnostic criteria as well as radiological and pathological correlation of these lesions. The description of EEG changes in SCGs is limited to local experience of 83 cases, the authors having failed to include the experience of others. The correlation between EEG changes, seizure type and CT findings is not impressive. The section on immunological tests in the management of SCGs deals with enzyme-linked immunoadsorbent assay and enzyme-linked immunoelectrotransfer blots; it includes the local experience in addition to a good review of literature. The sensitivity and specificity of both the tests is discussed.
The editors have been quite daring to carry out stereotactic biopsies of SSECTLs, which are benign and spontaneously resolve. This led to the confirmation of diagnosis of SCGs in these cases. The chapter on pathogenesis and pathology of neurocysticercosis describes the pathology of SSECTLs based on the biopsy material of 43 cases. It is well illustrated and gives a good clinico-radiological and pathological correlation.
Medical management of SCGs inadequately portrays anticonvulsant drugs and cysticidal therapy. The authors make an important recommendation that the majority of patients with SSECTLs require only short term therapy, a point which needs to be supported by sound clinical trials. The only cysticidal therapy discussed is albendazole and praziquantel is conspicuous by its absence. The arguments given for use of albendazole therapy are opinions based on theoretical grounds rather than sound clinical trials. They advocate use of steroids along with albendazole, which is not the current practice in many centres. In their own experience, they have found the side-effects of albendazole on a group treated with steroids to be no different to those in a group who were not given steroids.
Surgical intervention in SSECTLs has helped a great deal in understanding the cause of these lesions, but is rarely indicated in the practical management of these patients. This section is written with the rich experience of excising 61 granulomas over a decade. The monograph ends by examining the outcome of patients with SCGs. The discussion revolves around rate and pattern of resolution, reappearance of lesions and seizure outcome. There is a single contribution from outside India, that of Del Brutto, who describes these lesions based on his vast experience of neurocysticercosis in Latin America.
This monograph is the outcome of pioneering work of editors in the field of surgical intervention of SSECTLs. It is a good review of SCGs largely based on the experience in CMC Vellore, India, and reflects, therefore, a significant local bias. However, I have no hesitation in recommending it for all the physicians involved in the treatment of epilepsy in those parts of the world where SCGs are endemic. It will also interest neurologists in developed countries who may have an occasional encounter with these patients.
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