What is the treatment for neurocysticercosis?

Treatment of Neurocysticercosis

For neurocysticercosis treatment, albendazole (15 mg/kg/day divided into 2 daily doses for 10-14 days, maximum 1200 mg/day) is recommended as first-line therapy for patients with 1-2 viable parenchymal cysts, while combination therapy with albendazole plus praziquantel is recommended for patients with >2 viable cysts. 1, 2

Initial Assessment and Management

Before initiating antiparasitic treatment:

1. Rule out contraindications:

   • Assess for elevated intracranial pressure or diffuse cerebral edema
   • If present, manage elevated pressure first with corticosteroids and/or surgical approach before antiparasitic treatment 1

2. Required diagnostic workup:

   • Both brain MRI and non-contrast CT scan 1
   • Fundoscopic examination to check for retinal lesions 1, 3

3. Pre-treatment screening:

   • Pregnancy test for females of reproductive potential 3
   • Consider screening for latent tuberculosis and Strongyloides in patients requiring prolonged corticosteroids 1

Treatment Algorithm Based on Disease Presentation

1. Viable Parenchymal Neurocysticercosis (VPN)

• For 1-2 viable cysts:

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

• For >2 viable cysts:

  • Combination therapy: Albendazole (15 mg/kg/day) plus praziquantel (50 mg/kg/day) for 10-14 days 1, 2
  • This combination increases parasiticidal effect without increased side effects 4

2. Single Enhancing Lesions (SELs)

• Albendazole therapy (same dosing as above) for 1-2 weeks 1
• Adjunctive corticosteroids initiated prior to antiparasitic therapy 1

3. Intraventricular or Subarachnoid Neurocysticercosis

• Surgical approach often required, especially for hydrocephalus 2
• Shunt surgery when surgical removal is difficult 2

Adjunctive Therapy

1. Corticosteroids:

   • Start prior to antiparasitic therapy to prevent neurological deterioration 1, 2
   • Options include dexamethasone or prednisone 2
   • Critical to prevent cerebral hypertensive episodes during first week of treatment 3

2. Antiepileptic drugs:

   • Recommended for all patients with seizures 1, 2
   • Can be tapered after 6 months if seizure-free and lesions have resolved 1, 2
   • Choice guided by local availability, cost, drug interactions, and potential side effects 1

Monitoring During Treatment

• Blood counts: At beginning of treatment and every 2 weeks 1, 3
• Liver enzymes: At beginning of treatment and at least every 2 weeks 3
• Imaging follow-up: MRI at least every 6 months until resolution of cystic component 1, 2

Treatment Response and Follow-up

• Consider retreatment if parenchymal cystic lesions persist for 6 months after initial therapy 1
• For patients with SELs who have been seizure-free for 6 months, consider tapering off antiepileptic drugs after lesion resolution 1

Common Pitfalls and Caveats

1. Do not initiate antiparasitic therapy without first:

   • Ruling out elevated intracranial pressure
   • Checking for retinal involvement
   • Starting appropriate corticosteroids

2. Drug interactions:

   • Praziquantel may decrease serum concentrations of steroids 1
   • Praziquantel may lower serum levels of phenytoin and carbamazepine 1

3. Treatment reactions:

   • Exacerbation of neurological symptoms often occurs between the second and fifth days of antiparasitic therapy due to inflammation from dying parasites 1
   • This is why concurrent corticosteroid therapy is essential

4. Pregnancy considerations:

   • Albendazole may cause fetal harm; ensure pregnancy testing before initiating therapy 3

The evidence strongly supports antiparasitic therapy for neurocysticercosis, with treatment regimens tailored to the number and location of cysts, providing significant improvement in both radiological findings and clinical outcomes.