Symptoms and Treatment of Neurocysticercosis (Tapeworm in the Brain)
The two most common clinical presentations of neurocysticercosis (NCC) are seizures and increased intracranial pressure, with seizures accounting for approximately 29% of cases in endemic areas and about 2% of seizure presentations in US emergency rooms. 1
Clinical Manifestations
Common Symptoms
- Seizures (focal, focal with generalization, or generalized) - the most frequent presentation 1
- Headaches, including migraine-type headaches 1
- Increased intracranial pressure, mainly from obstructive hydrocephalus (occurs in approximately 20% of cases) 1
Less Common Manifestations
- Focal neurological deficits 1
- Spinal radiculopathies 1
- Cerebrovascular accidents (lacunar infarctions, thrombotic, and hemorrhagic strokes) 1
- Visual changes 1
- Mass lesion effects 1
- Symptoms of hydrocephalus 1
Diagnosis
Imaging Studies
- Both brain MRI and non-contrast CT scan are recommended 1
- MRI is more sensitive for detection of:
- The scolex (parasite head)
- Edema
- Small parenchymal lesions
- Posterior fossa lesions
- Subarachnoid and ventricular involvement 1
- CT is more sensitive for detecting calcified lesions 1
- FLAIR sequences are particularly helpful for identifying associated edema and the scolex 1
Laboratory Testing
- Serologic testing with enzyme-linked immunotransfer blot is recommended as a confirmatory test 1
- Enzyme-linked immunosorbent assays (ELISAs) using crude antigen should be avoided due to poor sensitivity and specificity 1
- Fundoscopic examination is mandatory prior to initiating anthelmintic therapy to rule out ocular involvement 1
Treatment Approach
Initial Management
- For patients with untreated hydrocephalus or diffuse cerebral edema, manage elevated intracranial pressure first before considering antiparasitic treatment 1
- For diffuse cerebral edema: anti-inflammatory therapy with corticosteroids 1
- For hydrocephalus: surgical approach is usually required 1
Antiparasitic Treatment for Viable Parenchymal Neurocysticercosis (VPN)
- For 1-2 viable parenchymal cysticerci: albendazole monotherapy for 10-14 days 1
- Dose: 15 mg/kg/day divided into 2 daily doses (maximum 1200 mg/day) 1
- For >2 viable parenchymal cysticerci: albendazole (15 mg/kg/day) combined with praziquantel (50 mg/kg/day) for 10-14 days 1
- Consider retreatment if cystic lesions persist for 6 months after initial therapy 1
Anticonvulsant Therapy
- Antiepileptic drugs are recommended for all patients with seizures 1
- For patients who have been seizure-free for 6 months, consider tapering off antiepileptic drugs after resolution of the lesion if there are no risk factors for recurrent seizures 1
- Risk factors for recurrent seizures include: residual cystic lesions or calcifications, breakthrough seizures, or >2 seizures 1
Corticosteroid Therapy
- Corticosteroids should be given with antiparasitic drugs to prevent neurological symptoms due to inflammatory reactions 2
- For neurocysticercosis treatment: dexamethasone or prednisone/prednisolone 1
Monitoring During Treatment
- Monitor blood counts at the beginning of treatment and every 2 weeks during therapy with albendazole 1, 2
- Monitor liver enzymes (transaminases) before starting treatment and at least every 2 weeks during treatment 1, 2
- Discontinue albendazole if clinically significant decreases in blood cell counts occur 2
- MRI should be repeated at least every 6 months until resolution of the cystic component 1
- Screen for latent tuberculosis infection and Strongyloides stercoralis in patients likely to require prolonged corticosteroids 1
Important Precautions
- Perform fundoscopic examination prior to initiating anthelmintic therapy to rule out ocular involvement 1
- Antiparasitic agents can worsen cerebral edema and should be avoided in patients with increased intracranial pressure 1
- Albendazole may cause bone marrow suppression, aplastic anemia, and agranulocytosis 2
- Albendazole may cause fetal harm; pregnancy testing is recommended for females of reproductive potential prior to therapy 2
- Consider screening household members for tapeworm carriage, especially in non-endemic areas 1