What is the treatment for neurocysticercosis?

Treatment of Neurocysticercosis

For neurocysticercosis treatment, antiparasitic therapy with albendazole (alone or in combination with praziquantel), corticosteroids, and antiepileptic drugs is recommended based on the specific form of disease, with treatment tailored according to the number, location, and viability of cysts. 1

Initial Evaluation and Diagnosis

• Neuroimaging with both brain MRI and non-contrast CT scan is essential for diagnosis and treatment planning 1
• Serologic testing with enzyme-linked immunotransfer blot is recommended as a confirmatory test (avoid ELISA using crude antigen due to poor sensitivity and specificity) 1
• All patients should undergo fundoscopic examination prior to initiating antiparasitic therapy to check for retinal lesions 1, 2

Treatment Approach Based on Disease Form

Viable Parenchymal Neurocysticercosis (VPN)

• For patients with 1-2 viable parenchymal cysticerci:

  • Albendazole monotherapy for 10-14 days (15 mg/kg/day divided into 2 daily doses, maximum 1200 mg/day) 1, 2
  • Take with food to improve absorption 2
  • For patients ≥60 kg: 400 mg twice daily; <60 kg: 15 mg/kg/day in divided doses 2

• For patients with >2 viable parenchymal cysticerci:

  • Combination therapy with albendazole (15 mg/kg/day) plus praziquantel (50 mg/kg/day) for 10-14 days 1
  • This combination has shown superior radiologic resolution compared to albendazole alone 1

• For all VPN patients:

  • Corticosteroids should be given whenever antiparasitic drugs are used 1, 2
  • Antiepileptic drugs should be used in all patients with seizures 1
  • Consider retreatment if cystic lesions persist for 6 months after initial therapy 1
  • Follow-up MRI should be performed at least every 6 months until resolution of cystic component 1

Single Enhancing Lesions (SELs)

• Albendazole (15 mg/kg/day in 2 daily doses up to 800 mg/day) for 1-2 weeks 1
• Corticosteroids should be given concomitantly with antiparasitic agents 1
• Antiepileptic drugs for all patients with seizures 1
• Consider tapering off antiepileptic drugs after 6 months if seizure-free and lesion has resolved 1

Calcified Parenchymal Neurocysticercosis

• Antiparasitic treatment is not recommended (no viable cysts) 1
• Antiepileptic drugs should be used for seizure control 1
• Corticosteroids are not routinely recommended 1

Cysticercal Encephalitis (with Diffuse Cerebral Edema)

• Avoid antiparasitic drugs 1
• Treat with corticosteroids to manage cerebral edema 1
• Manage elevated intracranial pressure before considering antiparasitic treatment 1

Ventricular and Subarachnoid Neurocysticercosis

• Surgical approach is often needed for ventricular cysts, though medical therapy may be beneficial 1, 3
• For giant subarachnoid cysts, intensive medical treatment with albendazole (15 mg/kg/day for 4 weeks) can be effective 3
• Ventriculoperitoneal shunting may be required for hydrocephalus 3

Adjunctive Therapies

Corticosteroids

• Essential when using antiparasitic drugs to reduce inflammatory response 1
• Common regimens include dexamethasone 4.5-12 mg/day or prednisone 1 mg/kg/day 1
• Higher doses (up to 32 mg/day of dexamethasone) may be needed for cysticercosis arachnoiditis or encephalitis 1

Antiepileptic Drugs

• Recommended for all patients with seizures 1
• Can be discontinued after resolution of cystic lesions if no risk factors for recurrence 1
• Risk factors for recurrent seizures: calcifications on follow-up CT, breakthrough seizures, >2 seizures during disease course 1

Monitoring and Safety

• 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
• Monitor blood counts at the beginning of therapy and every 2 weeks for patients on albendazole >14 days 1, 2
• Monitor liver enzymes (transaminases) at the beginning of therapy and every 2 weeks 2
• Obtain pregnancy test in females of reproductive potential prior to therapy 2

Special Considerations

• Household members of patients who acquired neurocysticercosis in non-endemic areas should be screened for tapeworm carriage 1
• Patients with untreated hydrocephalus or diffuse cerebral edema should receive management for elevated intracranial pressure before antiparasitic treatment 1
• Albendazole may cause fetal harm; advise females of reproductive potential to use effective contraception during treatment and for 3 days after 2
• Risk of retinal damage in patients with retinal neurocysticercosis - examine for retinal lesions before starting therapy 2

Common Pitfalls

• Using antiparasitic drugs in patients with calcified parasites or cysticercosis encephalitis 1
• Withholding antiparasitic treatment when it is the best option, such as for growing cysts 1
• Failure to provide corticosteroids when using antiparasitic drugs, which can lead to worsening neurological symptoms 1, 2
• Not monitoring for bone marrow suppression and hepatotoxicity during albendazole therapy 2