What is the treatment for neurocysticercosis?

Treatment of Neurocysticercosis

Albendazole (15 mg/kg/day in twice-daily doses for 10-14 days) is the first-line therapy for neurocysticercosis, and must be administered with corticosteroids initiated prior to antiparasitic treatment. 1

Treatment Approach Based on Type of Neurocysticercosis

Parenchymal Neurocysticercosis

• For 1-2 viable cysts:

  • Albendazole 15 mg/kg/day divided into 2 daily doses for 10-14 days (maximum 1200 mg/day) 1
  • Must be taken with food to increase absorption 2

• For >2 viable cysts:

  • Combination therapy with albendazole (15 mg/kg/day) plus praziquantel (50 mg/kg/day) for 10-14 days 1
  • This combination increases albendazole sulfoxide plasma concentrations, potentially improving efficacy 3

• For single enhancing lesions (SELs):

  • Albendazole therapy rather than no antiparasitic therapy 4
  • Duration: 1-2 weeks 4

• For calcified parenchymal neurocysticercosis:

  • Symptomatic therapy alone (antiparasitic drugs not recommended) 4, 1
  • Antiepileptic drugs for seizure control if needed

Intraventricular Neurocysticercosis

1. First option: Removal of cysticerci by minimally invasive neuroendoscopy (for lateral and third ventricles) 4
2. If surgical removal is difficult: Shunt surgery for hydrocephalus 4, 1
3. After shunt insertion: Consider antiparasitic drugs with corticosteroid therapy to decrease subsequent shunt failure 4

Subarachnoid Neurocysticercosis

• Antiparasitic drugs with high-dose corticosteroids 4
• Continue therapy until radiologic resolution of viable cysticerci on MRI (may require >1 year) 4

Essential Adjunctive Therapies

Corticosteroids

• Must be initiated prior to antiparasitic therapy to prevent neurological deterioration 4, 1, 2
• Options include:
  • Dexamethasone 0.1 mg/kg/day or
  • Prednisone 1-1.5 mg/kg/day 1
• Particularly important days 2-5 of treatment when inflammation from dying parasites peaks 1

Antiepileptic Drugs

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

Monitoring During Treatment

1. Before treatment:

   • Pregnancy test in females of reproductive potential 2
   • Blood counts and liver enzymes 2
   • Fundoscopic examination to check for retinal lesions 1, 2

2. During treatment:

   • Blood counts every 2 weeks 1, 2
   • Liver enzymes at least every 2 weeks 2
   • Monitor for neurological symptoms 2

3. Follow-up:

   • MRI at least every 6 months until resolution of cystic lesions 4, 1
   • Consider retreatment if parenchymal cystic lesions persist for 6 months after initial therapy 1

Important Cautions and Considerations

• Exacerbation of neurological symptoms often occurs between days 2-5 of antiparasitic therapy due to inflammation from dying parasites 1
• Manage elevated intracranial pressure before initiating antiparasitic treatment 1
• Praziquantel may decrease serum concentrations of steroids and lower serum levels of phenytoin and carbamazepine 1
• Albendazole may cause bone marrow suppression; discontinue if clinically significant decreases in blood cell counts occur 2
• Albendazole may cause fetal harm; pregnancy testing and contraception are essential 2

Surgical Considerations

• For refractory epilepsy with calcified parenchymal neurocysticercosis, consider evaluation for surgical removal of seizure foci 4
• Fourth ventricular cysticerci should be surgically removed rather than treated medically when possible 4

Neurocysticercosis treatment should be tailored to the specific type of disease (parenchymal, intraventricular, or subarachnoid) and stage of lesions, with appropriate antiparasitic therapy, corticosteroids, and management of complications.