Beyond Imaging: A 12-Year Clinicopathological Analysis of Surgically Excised Neurocysticercosis

Background: Neurocysticercosis (NCC), caused by the larval stage of Taenia solium, is the most prevalent parasitic infection of the central nervous system (CNS) and a leading cause of acquired epilepsy in endemic regions. Although neuroimaging has substantially improved the diagnosis of NCC, radiological appearances may vary according to the stage of the parasite and often overlap with neoplastic, inflammatory, and other infectious lesions. Consequently, histopathological examination remains the definitive diagnostic modality in surgically excised cases. Methods: This retrospective clinicopathological study included 26 histopathologically diagnosed cases of surgically excised NCC over a 12-year period from January 2014 to December 2025 at a tertiary care center in Northern India. Demographic profile, clinical presentation, and radiological findings were retrieved from patient case files and the hospital information system. Operative notes were reviewed to document intraoperative findings and the provisional intraoperative diagnosis. Histological sections were reviewed to confirm the diagnosis, evaluate parasite morphology, and assess host inflammatory response and associated tissue changes. The diagnostic accuracy of radiological tests and intraoperative assessment was evaluated, with histopathological diagnosis as the gold standard. Results: Twenty-six patients were identified, ranging in age from 11 to 68 years (mean, 32.0 years), with a male predominance (male: female ratio, 2.7:1). The majority of cases presented with signs and symptoms of raised intracranial pressure, including headache (22/26, 84.6%), followed by vomiting (16/26, 61.5%). Obstructive hydrocephalus was noted in 73.1% (19/26) of cases, all of which were localized in ventricles or cisterns. Depending on the location of the parasitic cyst, other presenting manifestations included focal or generalized seizures (6/26, 23.1%), visual disturbances (3/26, 11.5%), gait abnormalities (3/26, 11.5%), meningitis (3/26, 11.5%), and focal neurological deficits (2/26, 7.7%). The mean duration of symptoms was 8.2 months (range, 1-36 months). Lesion size ranged from 8 to 60 mm (mean, 21.3 mm). Preoperative radiological diagnosis correctly suggested NCC in 53.8% (14/26) of cases, whereas intraoperative diagnosis was accurate in 69.2% (18/26). Histopathological examination established the diagnosis in all cases and demonstrated variable stages of parasite degeneration, with an associated inflammatory reaction in 30.8% (8/26) of cases and calcification in 19.2% (5/26) of cases. The most common morphological stages of the parasite were the vesicular and colloidal stages, together accounting for 61.5% (16/26) of cases. Conclusions: CNS NCC exhibits diverse clinical and radiological manifestations that may pose significant diagnostic challenges. In surgically excised lesions, histopathological evaluation remains indispensable for definitive diagnosis and provides valuable insights into parasite viability, host inflammatory response, and disease evolution. Our findings underscore the limitations of imaging alone and highlight the complementary role of histopathology in achieving accurate diagnosis and guiding appropriate clinical management.