Unusual Presentation of Porencephalic Cyst in an Adult

Abstract

Porencephalic cyst is quite a rare entity in adults with only a few cases reported so far. It is usually congenital and seen in neonates.
Here, we report a 28-year-old female who presented with post-ictal confusion following a new onset of focal seizures with secondary
generalisation. She was diagnosed to have porencephalic cyst in left posterior parietal lobe on brain imaging. She was started on antiepileptic drugs and is on follow up.

Full text

Journal of Clinical and Diagnostic Research. 2017 Feb, Vol-11(2): OD12-OD13
1212
DOI: 10.7860/JCDR/2017/22654.9374
Case Report
CASE REPORT
A 28-year-old female presented with confusional state following three
episodes of seizures. It began as focal motor seizures involving right
arm and right leg and became generalized tonic – clonic seizures
associated with loss of consciousness. Each episode lasted for
about 1 minute with regaining of consciousness during inter-ictal
period. It was not associated with fever, headache, vomiting, head
trauma or focal neurological deficits. Alcohol and drug history was
insignificant. There was no history of similar complaints, perinatal
asphyxia, and developmental delay in the past. Family history was
unremarkable.
On general examination, patient was confused. Pulse was regular
with a rate of 90 beats/minute. All peripheral pulses were palpable.
Blood pressure was130/80 mmHg. Respiratory rate was 16
breaths/minute and regular in rhythm. Temperature was 98.8°F.
There were signs of tongue bite, frothing at the mouth and urinary
incontinence. There were no signs of trauma, meningeal irritation,
twitching of limbs and face, rash or neurocutaneous markers.
There was no pallor, icterus, clubbing, cyanosis, lymphadenopathy
or oedema.
On neurological examination, Glasgow coma scale was
8/15(E2V2M4). Cranial nerve examination demonstrated that pupils
were normal and reactive to light; corneal reflex, oculo-cephalic
reflex and gag reflex were present bilaterally. Ophthalmoscopy was
normal. Motor system examination showed generalized hypotonia
and areflexia. Bilateral plantar response was extensor. Other
systemic examination was unremarkable. The following day the
patient became conscious and oriented. Neurological examination
revealed recovery of motor functions, though Babinski reflex
persisted.
Haematological investigations revealed haemoglobin of 12.4 g/dl
with Red Blood Cell Count 3.5 million cells/μL, Mean Corpuscular
Volume (MCV) 78.8 fL, Mean Corpuscular Haemoglobin (MCH) 28.4
pg, Mean Corpuscular Haemoglobin Concentration (MCHC) 31.6
g/dl, Total Leukocyte Count (TLC) 8600/μL, Total Platelet Count
(TPC) 2.8 lakhs/μL, Erythrocyte Sedimentation Rate (ESR) 50 mm
in 1st hour, Differential Leukocyte Count showed neutrophils 78%,
lymphocytes 21%, eosinophils 1%, monocytes 0%, basophils 0%.
Serological investigations revealed random blood glucose 170 mg/
dl, urea 29 mg/dl, creatinine 1.1 mg/dl, Aspartate Aminotransferase
(AST) 257 IU/L, Alanine Aminotransferase (ALT) 143 IU/L, Alkaline
Keywords: Anti-epileptic drugs, Magnetic Resonance Imaging, Parietal lobe, Seizure
Internal Medicine
Section
Unusual Presentation of
Porencephalic Cyst
in an Adult
ABEL THOMAS OOMMEN1, GANESWAR SETHY2, NOAS TOBIAS MINZ3, JOGENDRA PATRA4, SWAYANG SUDHA PANDA5
ABSTRACT
Porencephalic cyst is quite a rare entity in adults with only a few cases reported so far. It is usually congenital and seen in neonates.
Here, we report a 28-year-old female who presented with post-ictal confusion following a new onset of focal seizures with secondary
generalisation. She was diagnosed to have porencephalic cyst in left posterior parietal lobe on brain imaging. She was started on anti-
epileptic drugs and is on follow up.
Phosphatase (ALP) 45 IU/L, total bilirubin 0.6mg/dl, direct bilirubin
0.2 mg/dl, protein 6.8 g/dl, Na+(137meq/l), K+(3.8meq/l), Ca2+(9.8
mg/dl), Mg2+(2.1 meq/l). Urine routine and microscopy was normal.
Homocysteine level, Factor V Leiden mutation, Anti-phospholipid
antibodies and Anti-thrombin lll were within normal limits. Auto-
antibodies against potassium channels and glutamate receptors
were absent.
Electroencephalogram (EEG) was normal. CT scan of the brain was
suggestive of hypodense lesion in left posterior parietal lobe [Table/
Fig-1] with dilatation of ipsilateral occipital horn of left lateral ventricle
[Table/Fig-2], but inconclusive. MRI showed T1 hypo intense [Table/
Fig-3], T2 [Table/Fig-4] and Fluid Attenuation Inversion Recovery
(FLAIR) hyperintense signal in left posterior parietal region with focal
irregularity of gyral pattern and dilatation of occipital horn. There
was no restriction of diffusion noted in lesion in Diffusion Weighted
Imaging (DWI). Apparent Diffusion Coefficient (ADC) exhibited hyper
intense signal in the lesion. There were no abnormal flow voids.
The lesion was non-enhancing and perifocal irregular nodular
foci of enhancement were noted in post-contrast study with no
perifocal oedema or mass effect [Table/Fig-5]. These features were
suggestive of a porencephalic cyst along the superior convexity of
left posterior parietal lobe with gliosis. The differential diagnoses
include cystic lesions such as arachnoid cyst, epidermoid cyst.
She was treated with anti-epileptic drugs (inj. Lorazepam and inj.
Valproate), i.v. Dexamethasone, i.v. Mannitol and intravenous fluid.
Her sensorium improved gradually and she was discharged on
Sodium Valproate tablets after a few days. On follow up patient
was found to be asymptomatic till last 6 months.
[Table/Fig-1]: Non-contrast computed tomography brain showing hypodense lesion
in left posterior parietal lobe. [Table/Fig-2]: With dilatation of ipsilateral occipital horn
of left lateral ventricle.

www.jcdr.net Abel Thomas Oommen et al., Unusual Presentation of Porencephalic Cyst in an Adult
Journal of Clinical and Diagnostic Research. 2017 Feb, Vol-11(2): OD12-OD13 1313
Keywords: Anti-epileptic drugs, Magnetic Resonance Imaging, Parietal lobe, Seizure
DISCUSSION
Porencephalic cyst is an uncommon intra-cranial cyst in adults. It
is a congenital or acquired cavity within the cerebral hemisphere.
It contains cerebrospinal fluid with smooth wall lined by gliotic or
spongiotic white matter. It usually communicates directly with the
ventricular system [1]. It varies greatly in size. It can be cortical
or sub-cortical, unilateral or bilateral and often seen in territories
supplied by the cerebral arteries. It has been suggested that,
porencephalic cysts are caused by a disturbance of vascular supply
leading to cerebral degeneration [2]. Congenital porencephalic cysts
result from intra-uterine vascular injury leading to cerebral ischemia
or intra-parenchymal haemorrhage. Intra-uterine infectious injury
by a virus like cytomegalovirus can also give rise to congenital
porencephalic cysts [3-5]. Amygdalar-hippocampal atrophy often
co-exists with congenital porencephaly (95%), and the atrophy may
be bilateral despite unilateral cysts [6]. Acquired cysts are secondary
to injury later in life due to trauma, surgery, ischemia, or infection
[7]. De novo or inherited heterozygous mutations in COL4A1, which
encodes the type IV a1 collagen chain that is essential for structural
integrity for vascular basement membranes, have been reported in
individuals with porencephaly [2]. Our case depicts a porencephalic
cyst in adulthood but the cause could not be ascertained.
Clinical features are variable as the cysts vary in size and location.
Patients may be asymptomatic or may present with epilepsy, focal
neurological deficits or mental retardation. Seizures may be partial
or generalized. Motor deficits range from hemiparesis to severe
atonic diplegia. Cognitive deficits vary from normal or slight learning
disability to severe mental retardation. Microcephaly is usually
associated [4,5]. EEG may help in the diagnosis, but the findings
are not specific. CT scan brain reveals a hypodense intracranial
cyst with a well defined border and central attenuation the same as
cerebrospinal fluid. Usually there is no mass effect on the adjacent
parenchyma, but occasionally very large cysts do result in local
mass effect. It does not show enhancement with contrast. On MRI
brain cyst appears well defined and lined by white matter with or
without gliosis. It contains cerebrospinal fluid signal with low signal
intensity in T1: high signal intensity in T2. FLAIR shows suppression
of fluid signal intensity and DWI with no restricted diffusion [8]. The
differential diagnosis for the porencephalic cyst includes arachnoid
cyst, schizencephaly, and ependymal cyst. Arachnoid cysts are
extra-axial and displace the brain cortex away from the adjacent
skull. Schizencephaly is a CSF-filled cavity that is lined with
heterotopic gray matter and extends all the way from the ventricle to
the brain surface. Ependymal cysts are typically intra-ventricular with
normal surrounding brain tissue [7]. Treatment may include physical
therapy, anti-epileptic drugs for seizure disorders, and a shunt in
case of hydrocephalus. Surgery is advised in the patients with anti-
epileptic drug resistant epilepsy. This includes hemispherectomy
and hemispherotomy, although usually performed in children and
in cases of large porencephalic cysts related to ischemia or trauma
[3-5]. Hemispherectomy is currently the surgical treatment of choice
for intractable seizures associated with large, unilateral hemisphere
porencephalic cysts and a neurologic deficit. An alternative
minimally-invasive approach is permanent endovascular balloon
occlusion in which the desired cerebral arteries are embolized. But
this approach has yet to prove its safety and efficacy [9]. In our
case; the patient was clinically asymptomatic following anti-epileptic
drug therapy.
CONCLUSION
Seizure is one of the most common neurological symptoms that
can arise from any insult to brain. Porencephalic cyst has diverse
clinical features. It may be asymptomatic or present with epilepsy or
spastic quadriparesis or mental retardation. Cases of porencephalic
cyst in adults are rare and are seldom reported. An atypical case
of this entity is discussed. Hence, porencephalic cyst should be
considered among other differential diagnoses for seizures, mostly
in children but also in adults.
REFERENCES
Osborn AG. Choroid plexus cyst. Diagnostic imaging. Brain. Salt Lake City, Utah: [1]
Amirsys. 2004;1:7-30.
Yoneda Y, Haginoya K, Arai H, Yamaoka S, Tsurusaki Y, Doi H, et al. De novo and [2]
inherited mutations in COL4A2, encoding the type IV collagen α2 chain cause
porencephaly. The American Journal of Human Genetics. 2012;90(1):86-90.
Ranjan M, Arivazhagan A, Chandrajit P, Chandramouli BA. Unusual manifestation [3]
of an orbital roof fracture in a child: Acute orbital leptomeningeal porencephalic
cyst. Neurology India. 2010;58(6):974-75.
Kokkinos V, Garganis K, Kontogiannis K, Zountsas B. Hemispherotomy [4]
or lobectomy? The role of presurgical neuroimaging in a young case of a
large porencephalic cyst with intractable epilepsy. Pediatric Neurosurgery.
2011;47(3):204-09.
Ozeki M, Funato M, Teramoto T, Ohe N, Asano T, Kaneko H, et al. Reversible [5]
cerebrospinal fluid oedema and porencephalic cyst, a rare complication of
ventricular catheter. Journal of Clinical Neuroscience. 2010;17(5):658-61.
Ho SS, Kuzniecky RI, Gilliam F, Faught E, Bebin M, Morawetz R. Congenital [6]
porencephaly: MR features and relationship to hippocampal sclerosis. American
Journal of Neuroradiology. 1998;19(1):135-41.
Osborn AG. Porencephalic cyst. Diagnostic imaging. Brain. Salt Lake City, Utah: [7]
Amirsys. 2004;1:7-36.
Ramsey RG, Huckman MS. Computed tomography of porencephaly and other [8]
cerebrospinal fluid-containing lesions. Radiology. 1977;123(1):73-77.
Phillips J, Roberts G, Brennan P, Staunton H. Minimally-invasive endovascular [9]
occlusion therapy in two adults for seizures associated with congenital
porencephalic cysts. Journal of Epilepsy. 1998;11(6):374-82.
PARTICULARS OF CONTRIBUTORS:
1 Junior Resident, Department of General Medicine, MKCG Medical College and Hospital, Brahmapur, Odisha, India.
2. Associate Professor, Department of General Medicine, MKCG Medical College and Hospital, Brahmapur, Odisha, India.
3. Assistant Professor, Department of General Medicine, MKCG Medical College and Hospital, Brahmapur, Odisha, India.
3. Senior Resident, Department of General Medicine, MKCG Medical College and Hospital, Brahmapur, Odisha, India.
5. Junior Resident, Department of General Medicine, MKCG Medical College and Hospital, Brahmapur, Odisha, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Abel Thomas Oommen,
Room No: 3, PG Hostel 2, MKCG Medical College, Brahmapur-760004, Odisha, India.
E-mail: abelthomas101@gmail.com
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Aug 18, 2016
Date of Peer Review: Oct 01, 2016
Date of Acceptance: Oct 21, 2016
Date of Publishing: Feb 01, 2017
[Table/Fig-3]: MRI brain showing cystic lesion in left posterior parietal lobe with
gliosis, T1 weighted MRI coronal-hypo intense signal; [Table/Fig-4]: MRI brain
showing cystic lesion in left posterior parietal lobe with gliosis, T2 weighted MRI
coronal iso- to hyper- intense signal; [Table/Fig-5]: MRI brain showing cystic lesion
in left posterior parietal lobe with gliosis, axial T1 contrast MRI with non-enhancing
lesion.