Management of Neurocysticercosis
The management of neurocysticercosis requires antiparasitic therapy with albendazole (15 mg/kg/day divided into 2 daily doses for 10-14 days), preceded by corticosteroid therapy, with treatment approach tailored to the specific form of neurocysticercosis (parenchymal, intraventricular, or calcified). 1, 2
Initial Evaluation
- Brain imaging: Both MRI and non-contrast CT scan are recommended for proper classification of neurocysticercosis lesions 1
- Fundoscopic examination: Must be performed prior to initiating antiparasitic therapy to rule out retinal lesions 1, 3
- Laboratory tests: Obtain baseline complete blood count and liver function tests 2
- Screening: Consider screening for latent tuberculosis and Strongyloides stercoralis before starting corticosteroids 1, 2
Treatment Algorithm Based on Disease Form
1. Parenchymal Neurocysticercosis with Viable Cysts
For 1-2 viable cysts:
For >2 viable cysts:
2. Single Enhancing Lesions (SELs)
- Albendazole: 15 mg/kg/day in twice-daily doses for 1-2 weeks 1
- Corticosteroids: Must be initiated prior to antiparasitic therapy 1
- Antiepileptic drugs: For all patients with SELs and seizures 1
3. Calcified Parenchymal Neurocysticercosis
- Symptomatic therapy alone (no antiparasitic drugs) 1
- Antiepileptic drugs for seizure control 1
- Corticosteroids not routinely recommended for isolated calcified lesions with perilesional edema 1
- Consider surgical evaluation for refractory epilepsy 1
4. Intraventricular Neurocysticercosis
- Surgical approach: Surgical removal of cysticerci is recommended when possible, especially for fourth ventricular cysts 1
- For hydrocephalus: Shunt surgery when surgical removal is technically difficult 1
- Perioperative management: Corticosteroids to decrease brain edema 1
- Post-shunt therapy: Consider antiparasitic drugs with corticosteroids after shunt insertion 1
5. Special Situations
- Elevated intracranial pressure/diffuse cerebral edema: Manage elevated pressure first; avoid antiparasitic drugs initially 1
- For cerebral edema: Anti-inflammatory therapy with corticosteroids
- For hydrocephalus: Surgical approach (shunting)
Medication Administration
- Albendazole: 15 mg/kg/day divided into 2 daily doses (maximum 1200 mg/day) for 10-14 days; should be taken with food 1, 3
- Corticosteroids: Dexamethasone 6-8 mg/day, started at least one day before antiparasitic therapy 2
- Antiepileptic drugs: Choice guided by local availability, cost, drug interactions, and potential side effects 1
Monitoring During Treatment
- Blood counts: Monitor at the beginning of therapy and every 2 weeks 1, 2, 3
- Liver enzymes: Monitor at the beginning of therapy and at least every 2 weeks 1, 2, 3
- Neurological status: Monitor for signs of increased intracranial pressure 2
Follow-up and Retreatment
- Imaging: MRI should be repeated at least every 6 months until resolution of cystic lesions 1
- Retreatment: Consider for parenchymal cystic lesions persisting for 6 months after initial therapy 1
- Antiepileptic drugs: Consider tapering off after 24 months of seizure freedom in patients with resolved lesions and few seizures prior to therapy 1
Common Pitfalls and Caveats
- Failure to start corticosteroids before antiparasitic therapy can lead to severe neurological deterioration due to inflammatory reactions 2
- Patients with liver disease or hepatic echinococcosis are at increased risk for bone marrow suppression and require more frequent monitoring 3
- Antiparasitic treatment should be avoided in patients with untreated hydrocephalus or diffuse cerebral edema until these conditions are managed 1
- Pregnancy testing is recommended before starting albendazole due to potential embryo-fetal toxicity 3