Diagnosis and Treatment of Neurocysticercosis
The diagnosis of neurocysticercosis requires both neuroimaging (MRI and CT) and serologic confirmation with enzyme-linked immunotransfer blot, while treatment must be tailored to the specific form of disease, with albendazole as the primary antiparasitic agent for most cases. 1
Clinical Presentation
- The two most common clinical presentations of neurocysticercosis (NCC) are seizures and increased intracranial pressure 1
- Other manifestations depend on location, number, size, and stage of the parasites 2
Diagnostic Approach
Neuroimaging
- Both brain MRI and non-contrast CT scan are recommended for complete evaluation 1
- MRI better visualizes the cystic component and inflammatory response
- CT better demonstrates calcifications 3
Serologic Testing
- Enzyme-linked immunotransfer blot is recommended as the confirmatory serologic test 1
- Enzyme-linked immunosorbent assays using crude antigen should be avoided due to poor sensitivity and specificity 1
Pre-Treatment Evaluation
- Fundoscopic examination is mandatory prior to initiating anthelmintic therapy to rule out retinal involvement 1, 4
- Screen for latent tuberculosis infection in patients likely to require prolonged corticosteroids 1
- Screen or provide empiric therapy for Strongyloides stercoralis in patients likely to require prolonged corticosteroids 1
- Pregnancy testing is recommended for females of reproductive potential prior to therapy 4
Treatment Approach Based on NCC Type
1. Viable Parenchymal Neurocysticercosis (VPN)
For 1-2 viable parenchymal cysticerci:
For >2 viable parenchymal cysticerci:
- Combination therapy with albendazole (15 mg/kg/day) plus praziquantel (50 mg/kg/day) for 10-14 days 1
Adjunctive therapy:
2. Patients with Elevated Intracranial Pressure
- In patients with untreated hydrocephalus or diffuse cerebral edema:
3. Single Enhancing Lesions (SELs)
- Albendazole therapy (15 mg/kg/day in twice-daily doses for 1-2 weeks) 1
- Antiepileptic drugs for all patients with SELs and seizures 1
- Consider tapering antiepileptic drugs after 6 months if seizure-free and lesion has resolved 1
4. Ventricular and Subarachnoid NCC
- Ventricular cysts: Primarily surgical approach, though some lateral ventricle cysts may respond to medical therapy 6
- Subarachnoid cysts: Medical therapy with albendazole may be effective 6
Monitoring During Treatment
- Monitor blood counts at the beginning of therapy and every 2 weeks while on albendazole 1, 4
- Monitor liver enzymes (transaminases) at the beginning of therapy and at least every 2 weeks during treatment 4
- Discontinue albendazole if clinically significant decreases in blood cell counts or elevations in liver enzymes occur 4
- Follow-up MRI should be performed at least every 6 months until resolution of the cystic component 1
Public Health Considerations
- Screen household members for tapeworm carriage in patients who likely acquired NCC in a non-endemic area 1
Treatment Complications and Pitfalls
- Risk of neurological deterioration: Death of parasites can cause inflammatory reaction leading to seizures, increased intracranial pressure, and focal signs 4
- Bone marrow suppression: Albendazole may cause granulocytopenia or pancytopenia; monitor blood counts carefully 4
- Hepatotoxicity: Treatment with albendazole has been associated with mild to moderate elevations of hepatic enzymes 4
- Embryo-fetal toxicity: Albendazole may cause fetal harm; effective contraception is required during treatment and for 3 days after the final dose 4
- Retinal damage: Examine for retinal lesions before initiating therapy; weigh risks and benefits if such lesions are present 4