What is the recommended treatment for neurocysticercosis?

Treatment of Neurocysticercosis

For neurocysticercosis treatment, antiparasitic drugs are recommended in all patients with viable parenchymal neurocysticercosis (VPN) unless there is elevated intracranial pressure or diffuse cerebral edema. 1

Initial Evaluation

• Both brain MRI and non-contrast CT scan are essential for diagnosis 1
• Serologic testing with enzyme-linked immunotransfer blot is recommended as a confirmatory test 1
• Fundoscopic examination must be performed prior to initiating antiparasitic therapy to check for retinal lesions 1, 2
• Screen for latent tuberculosis infection and Strongyloides stercoralis in patients likely to require prolonged corticosteroids 1

Treatment Algorithm Based on Disease Presentation

1. Viable Parenchymal Neurocysticercosis (VPN)

• For 1-2 viable parenchymal cysticerci:

  • Albendazole monotherapy (15 mg/kg/day divided in 2 daily doses, maximum 1200 mg/day) for 10-14 days with food 1, 2

• For >2 viable parenchymal cysticerci:

  • Combination therapy with albendazole (15 mg/kg/day) plus praziquantel (50 mg/kg/day) for 10-14 days 1

2. Single Enhancing Lesions (SELs)

• Albendazole (15 mg/kg/day in twice-daily doses) for 1-2 weeks 1, 3
• Always administer with meals to improve absorption 2, 4

3. Calcified Parenchymal Neurocysticercosis (CPN)

• Symptomatic therapy alone; antiparasitic drugs not recommended 1
• Corticosteroids not routinely used in patients with isolated CPN and perilesional edema 1

4. Intraventricular Neurocysticercosis

• Surgical removal recommended when technically feasible 1
• If surgical removal is difficult, shunt surgery for hydrocephalus is suggested 1

5. Cysticercal Encephalitis (with diffuse cerebral edema)

• Avoid antiparasitic drugs 1
• Treat diffuse cerebral edema with corticosteroids 1

Essential Adjunctive Therapy

Anti-inflammatory Therapy

• Corticosteroids must be initiated prior to antiparasitic therapy 1, 3, 2
• Options include:
  • Dexamethasone (standard doses) during the first several days of antiparasitic therapy 5
  • Prednisone (1-1.5 mg/kg/day) 3, 4

Antiepileptic Drugs

• Recommended for all patients with seizures 1, 3
• Can be tapered after 6 months if patient is seizure-free and lesions have resolved 1
• Continue if risk factors for recurrent seizures exist (residual cystic lesions/calcifications, breakthrough seizures, or >2 seizures) 1

Monitoring and Follow-up

• MRI should be repeated at least every 6 months until resolution of cystic component 1, 3
• Monitor blood counts at the beginning of therapy and every 2 weeks during treatment 2
• Monitor liver enzymes (transaminases) at the beginning of therapy and at least every 2 weeks 2
• Consider retreatment if parenchymal cystic lesions persist for 6 months after initial therapy 1

Important Precautions

• Pregnancy testing is recommended for females of reproductive potential prior to therapy 2
• Discontinue albendazole if clinically significant decreases in blood cell counts occur 2
• Patients with liver disease are at increased risk for bone marrow suppression and warrant more frequent monitoring 2

Treatment Pitfalls to Avoid

1. Administering antiparasitic drugs in patients with elevated intracranial pressure or diffuse cerebral edema
2. Failing to start corticosteroids before antiparasitic therapy
3. Not performing fundoscopic examination before starting treatment
4. Overlooking the need for combination therapy in patients with multiple (>2) cysts
5. Inadequate monitoring of blood counts and liver enzymes during treatment