What is the treatment for neurocysticercosis?

Treatment of Neurocysticercosis

The treatment of neurocysticercosis should include albendazole (15 mg/kg/day divided into 2 daily doses for 10-14 days, maximum 1200 mg/day) for patients with 1-2 viable parenchymal cysts, and combination therapy with albendazole plus praziquantel (50 mg/kg/day) for patients with >2 viable parenchymal cysts, along with appropriate corticosteroids and antiepileptic drugs as needed. 1, 2, 3

Treatment Algorithm Based on Cyst Type and Location

1. Viable Parenchymal Neurocysticercosis (VPN)

• For 1-2 viable cysts:

  • Albendazole 15 mg/kg/day divided into 2 daily doses for 10-14 days (maximum 1200 mg/day) 1, 2, 3
  • Take with food to improve absorption

• For >2 viable cysts:

  • Combination therapy: Albendazole (15 mg/kg/day) plus praziquantel (50 mg/kg/day) for 10-14 days 1, 2, 4
  • Combination therapy has shown superior cyst resolution (64% vs 37% with standard albendazole alone) 4

2. Single Enhancing Lesions (SELs)

• Albendazole 15 mg/kg/day in twice-daily doses for 1-2 weeks 1, 2
• Must be given with corticosteroids initiated prior to antiparasitic therapy 1

3. Calcified Parenchymal Neurocysticercosis

• No antiparasitic therapy needed 2
• MRI recommended in patients with seizures or hydrocephalus who have only calcified lesions on CT 1

4. Intraventricular Neurocysticercosis

• Surgical removal recommended when technically feasible, rather than medical therapy or shunt surgery 1, 2

5. Cases with Elevated Intracranial Pressure/Diffuse Cerebral Edema

• Manage elevated intracranial pressure first; delay antiparasitic treatment 1
• For diffuse cerebral edema: anti-inflammatory therapy (corticosteroids)
• For hydrocephalus: surgical approach 1

Adjunctive Therapies

Corticosteroids

• Must be initiated prior to antiparasitic therapy 1, 2, 3
• Options include dexamethasone 0.1 mg/kg/day or prednisone 1-1.5 mg/kg/day 2
• Prevents neurological deterioration from inflammatory reaction caused by dying parasites 3

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
• Consider longer treatment if risk factors present (residual cystic lesions, calcifications, breakthrough seizures, or >2 seizures) 1

Monitoring and Follow-up

Laboratory Monitoring

• Monitor blood counts at the beginning of treatment and every 2 weeks during therapy 2, 3
• Monitor liver enzymes at the beginning of treatment and at least every 2 weeks 2, 3
• Pregnancy testing recommended before starting albendazole due to embryo-fetal toxicity 2, 3

Imaging Follow-up

• MRI should be repeated at least every 6 months until resolution of cystic component 1, 2
• Consider retreatment if parenchymal cystic lesions persist for 6 months after initial therapy 1, 2

Important Precautions

• Examine for retinal lesions before initiating therapy to prevent retinal damage 2, 3
• Discontinue albendazole if clinically significant decreases in blood cell counts occur 3
• Be aware of potential drug interactions: praziquantel may decrease serum concentrations of steroids and lower serum levels of phenytoin and carbamazepine 2
• Exacerbation of neurological symptoms often occurs between the second and fifth days of antiparasitic therapy 2

Special Considerations

• For patients who have failed initial therapy, consider retreatment with the same or alternative regimen 1, 5
• Patients with liver disease are at increased risk for bone marrow suppression and warrant more frequent monitoring 3
• Females of reproductive potential should use effective contraception during treatment and for 3 days after the final dose 3