What is the recommended treatment for neurocysticercosis?

Treatment of Neurocysticercosis

The recommended treatment for neurocysticercosis depends on the form of disease, with antiparasitic drugs indicated for all patients with viable parenchymal neurocysticercosis (VPN) unless there is elevated intracranial pressure or diffuse cerebral edema. 1, 2

Treatment Algorithm Based on Disease Form

1. Viable Parenchymal Neurocysticercosis (VPN)

• First step: Assess for elevated intracranial pressure or diffuse cerebral edema

  • If present: Manage elevated intracranial pressure first with corticosteroids and/or surgical approach; delay antiparasitic treatment 1
  • If absent: Proceed with antiparasitic therapy

• Antiparasitic regimen based on cyst number:

  • 1-2 viable cysts: Albendazole monotherapy 15 mg/kg/day divided in 2 daily doses (maximum 1200 mg/day) for 10-14 days with food 1, 2, 3
  • >2 viable cysts: Combination therapy with albendazole (15 mg/kg/day) plus praziquantel (50 mg/kg/day) for 10-14 days 1, 2
    • This combination has shown superior efficacy with 64% complete cyst resolution versus 37% with albendazole alone 4

• Always add:

  • Corticosteroids: Begin prior to antiparasitic therapy to prevent neurological deterioration 1, 2, 3
  • Antiepileptic drugs: For all patients with seizures 1, 2

2. Single Enhancing Lesions (SELs)

• Albendazole (15 mg/kg/day in twice-daily doses) for 1-2 weeks 1, 2
• Corticosteroids initiated prior to antiparasitic therapy 1, 2
• Antiepileptic drugs for all patients with seizures 1, 2

3. Calcified Parenchymal Neurocysticercosis (CPN)

• Antiparasitic drugs not recommended (no viable cysts) 1, 2
• Symptomatic therapy only
• Antiepileptic drugs for seizure control 1, 2

4. Intraventricular Neurocysticercosis

• Surgical removal recommended when technically feasible 1, 2
• Shunt surgery for hydrocephalus when surgical removal is difficult 2

Adjunctive Therapy

Corticosteroids

• Timing: Must be initiated prior to antiparasitic therapy 1, 2, 3
• Purpose: Prevents inflammatory reaction from dying parasites that can worsen neurological symptoms 2, 3
• Options: Dexamethasone 0.1 mg/kg/day or prednisone 1-1.5 mg/kg/day 2

Antiepileptic Drugs

• Recommended for all patients with seizures 1, 2
• Can be tapered after 6 months if seizure-free and lesions have resolved 2
• Consider longer treatment if risk factors present (calcifications, breakthrough seizures, >2 seizures) 1

Monitoring and Follow-up

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

Important Caveats

• Pregnancy testing is recommended before starting albendazole due to potential embryo-fetal toxicity 3
• Patients should be evaluated for retinal lesions before initiating therapy for neurocysticercosis 3
• Albendazole may cause bone marrow suppression; discontinue if significant decreases in blood cell counts occur 3
• Patients with liver disease are at increased risk for bone marrow suppression and warrant more frequent monitoring 3
• The 8-day regimen of albendazole has been shown to be effective in some studies, but current guidelines recommend 10-14 days 5, 1, 2

By following this treatment algorithm based on the form of neurocysticercosis and patient-specific factors, clinicians can optimize outcomes while minimizing treatment-related complications.