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 (50 mg/kg/day) is recommended for patients with >2 viable cysts. 1

Antiparasitic Treatment Algorithm

First-line Treatment Options:

• For 1-2 viable parenchymal cysts:

  • Albendazole 15 mg/kg/day divided into 2 daily doses for 10-14 days (maximum 1200 mg/day) 1
  • For patients ≥60 kg: 400 mg twice daily with meals 2
  • For patients <60 kg: 15 mg/kg/day in divided doses twice daily with meals (maximum 800 mg/day) 2

• For >2 viable parenchymal cysts:

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

Adjunctive Therapy (Critical):

• Corticosteroids: Must be initiated PRIOR to antiparasitic therapy 1, 2

  • Options include:
    • Dexamethasone 0.1 mg/kg/day OR
    • Prednisone 1-1.5 mg/kg/day 1
  • Purpose: To prevent neurological deterioration from inflammatory reactions caused by dying parasites 1, 2

• Antiepileptic drugs: For all patients with seizures 1

  • Can be tapered after 6 months if seizure-free and lesions have resolved
  • Consider longer treatment with risk factors (residual cysts, calcifications, breakthrough seizures)

Monitoring During Treatment

• Blood counts: At beginning of treatment and every 2 weeks during therapy 1, 2
• Liver enzymes: At beginning of treatment and every 2 weeks during therapy 1, 2
• Pregnancy test: Required before starting albendazole due to embryo-fetal toxicity 1, 2
• Neurological status: Monitor closely, especially between days 2-5 of treatment when inflammation from dying parasites often peaks 1

Special Clinical Scenarios

Non-viable Cysts:

• Symptomatic therapy alone is recommended
• Antiparasitic drugs are NOT recommended 1

Surgical Intervention Indications:

• Surgical removal when technically feasible (preferred over medical therapy or shunt surgery)
• Shunt surgery for hydrocephalus when surgical removal is difficult 1

Elevated Intracranial Pressure:

• Manage elevated pressure FIRST
• Delay antiparasitic treatment until pressure is controlled 1
• For diffuse cerebral edema: Anti-inflammatory therapy (corticosteroids) 1

Follow-up Protocol

• MRI follow-up: At least every 6 months until resolution of cystic component 1
• Consider retreatment if parenchymal cystic lesions persist for 6 months after initial therapy 1

Important Precautions

• Retinal examination: Examine for retinal lesions before initiating therapy 1, 2

• Drug interactions:

  • Praziquantel may decrease serum concentrations of steroids and lower levels of phenytoin and carbamazepine 1
  • Fatty meals improve absorption of albendazole 3
  • Dexamethasone can affect albendazole levels 3

• Bone marrow suppression risk: Higher in patients with liver disease; discontinue if significant decreases in blood cell counts occur 2

• Pregnancy considerations: Albendazole may cause fetal harm; contraception recommended during treatment and for 3 days after final dose 2

While some older studies suggested shorter treatment courses of 8 days 4, 5, the most current guidelines recommend 10-14 days of therapy for optimal outcomes in terms of morbidity, mortality, and quality of life 1.