How to manage restlessness in a patient with Neurocysticercosis (NCC) and intellectual disability?

Management of Restlessness in Patients with Neurocysticercosis and Intellectual Disability

For patients with neurocysticercosis (NCC) and intellectual disability experiencing restlessness, corticosteroid therapy is the first-line treatment, particularly if the restlessness is related to cerebral edema or inflammation associated with the parasitic infection.

Assessment of Restlessness in NCC Patients

Before initiating treatment, determine the potential causes of restlessness:

1. NCC-related causes:

   • Cerebral edema around calcified lesions (perilesional edema)
   • Increased intracranial pressure
   • Seizure activity (including subclinical seizures)
   • Cysticercal encephalitis with diffuse cerebral edema

2. Non-NCC causes that may coexist:

   • Medication side effects
   • Pain
   • Sleep disturbances
   • Environmental factors
   • Behavioral manifestations of intellectual disability

Treatment Algorithm

Step 1: Address Acute Cerebral Edema

• If perilesional edema or cysticercal encephalitis is present:
  • Administer corticosteroids (dexamethasone) 1
  • Avoid antiparasitic drugs if there is evidence of increased intracranial pressure or diffuse cerebral edema 1

Step 2: Control Seizures

• If seizures are present or suspected:
  • Initiate or optimize antiepileptic drugs (AEDs) 1
  • Choice of AED should consider drug interactions, side effects, and patient characteristics 1
  • Monitor for breakthrough seizures which may manifest as restlessness in patients with intellectual disability

Step 3: Manage Hydrocephalus if Present

• If hydrocephalus is contributing to increased intracranial pressure:
  • Consider neurosurgical consultation for shunt placement 1
  • Surgical intervention takes priority over antiparasitic treatment in this scenario

Step 4: Address Underlying NCC Based on Type

1. For viable parenchymal cysts:

   • Once intracranial pressure is controlled, consider antiparasitic therapy with corticosteroid coverage 1
   • For 1-2 cysts: Albendazole monotherapy (15 mg/kg/day divided in 2 doses, max 1200 mg/day) for 10-14 days 1
   • For >2 cysts: Combination of albendazole and praziquantel 1

2. For calcified lesions:

   • Symptomatic therapy only; antiparasitic drugs not recommended 1
   • Short-term corticosteroids may be considered if perilesional edema is present 2

Specific Management of Restlessness

1. Non-pharmacological approaches:

   • Structured environment with consistent routines
   • Minimize environmental stimuli that may trigger agitation
   • Regular physical activity appropriate to patient's capabilities 1

2. Pharmacological options if restlessness persists:

   • First-line: Optimize corticosteroid therapy if related to NCC inflammation 1
   • Second-line options (if restlessness resembles restless legs syndrome):
     • Dopaminergic agents (e.g., pramipexole, ropinirole) 3, 4
     • Gabapentin for neuropathic symptoms 4
     • Short-term benzodiazepines for severe cases, with caution due to risk of sedation and falls 3, 4

Monitoring and Follow-up

• Regular neuroimaging (MRI) every 6 months until resolution of cystic lesions 1
• Monitor for recurrent perilesional edema, which can occur repeatedly over years 2
• Assess for medication side effects, particularly with long-term corticosteroid use
• Consider methotrexate as a steroid-sparing agent if prolonged anti-inflammatory therapy is required 1

Important Caveats

• Never use antiparasitic drugs in patients with untreated hydrocephalus or diffuse cerebral edema as this can worsen symptoms 1
• Restlessness in patients with intellectual disability may be difficult to distinguish from seizure activity, pain, or other discomfort
• Patients with NCC and intellectual disability require careful monitoring as they may not be able to verbalize symptoms
• The burden of NCC is significant, with substantial impact on quality of life and disability-adjusted life years 5