What is the treatment for neurocysticercosis?

Treatment of Neurocysticercosis

Treatment of neurocysticercosis requires antiparasitic therapy with albendazole (with or without praziquantel depending on cyst burden), mandatory adjunctive corticosteroids, and antiepileptic drugs for seizure control, with the specific regimen determined by the number, location, and stage of cystic lesions. 1

Pre-Treatment Assessment

Before initiating any therapy, several critical evaluations must be completed:

• Perform fundoscopic examination to exclude intraocular cysticerci, as antiparasitic treatment can cause blindness in patients with retinal involvement 1, 2
• Obtain both brain MRI and non-contrast CT scan to determine the number, location, and stage of cystic lesions 1
• Assess for increased intracranial pressure or hydrocephalus, as these are absolute contraindications to antiparasitic therapy 1, 3
• Screen for latent tuberculosis and Strongyloides stercoralis if prolonged corticosteroid therapy is anticipated 1
• Obtain pregnancy test in females of reproductive potential prior to albendazole therapy 2

Treatment Algorithm Based on Disease Type

Viable Parenchymal Neurocysticercosis (1-2 Cysts)

For patients with 1-2 viable parenchymal cysts, use albendazole monotherapy at 15 mg/kg/day (maximum 1200 mg/day) divided into 2 daily doses with food for 10-14 days. 1 Combination therapy shows no additional benefit with this low cyst burden and adds unnecessary pharmacologic complexity 1

• Always administer corticosteroids concomitantly with antiparasitic drugs to reduce inflammatory response and prevent seizures during therapy 1, 3
• Initiate antiepileptic drugs immediately in all patients presenting with seizures 1, 3

Viable Parenchymal Neurocysticercosis (>2 Cysts)

For patients with more than 2 viable parenchymal cysts, use combination therapy with albendazole (15 mg/kg/day in 2 daily doses, maximum 1200 mg/day) plus praziquantel (50 mg/kg/day in 3 daily doses) for 10-14 days. 1 This combination demonstrates superior radiologic resolution compared to albendazole monotherapy in patients with higher cyst burdens 1

• Mandatory corticosteroid co-administration to prevent worsening neurological symptoms from inflammatory response 1, 2
• Antiepileptic drugs required for all patients with seizures 1, 3

Single Enhancing Lesion

For single enhancing lesions, use albendazole 15 mg/kg/day (maximum 800 mg/day) in 2 daily doses for 1-2 weeks. 1 Meta-analyses demonstrate improved seizure outcomes with this regimen 1

• Corticosteroids must be given concomitantly with antiparasitic agents to reduce inflammatory response 1, 3
• Antiepileptic drugs can be discontinued after resolution of cystic lesions if no risk factors for recurrence exist (calcifications on follow-up CT, breakthrough seizures, or >2 seizures during disease course) 1

Calcified Parenchymal Neurocysticercosis

Do not use antiparasitic treatment for calcified lesions, as there are no viable cysts and antiparasitic therapy provides no benefit. 1, 3

• Treat with antiepileptic drugs only for seizure control, following standard epilepsy management guidelines 1
• Corticosteroids should not be routinely used for calcified lesions 1

Cysticercal Encephalitis (Diffuse Cerebral Edema)

In patients with cysticercal encephalitis and diffuse cerebral edema, antiparasitic drugs are absolutely contraindicated and increase mortality risk—treat with corticosteroids alone. 1, 3 The cerebral edema is mediated by host inflammatory response, and antiparasitic drugs worsen edema and can be fatal 1, 3

Hydrocephalus or Elevated Intracranial Pressure

In patients with untreated hydrocephalus or elevated intracranial pressure, manage the increased intracranial pressure first and do not initiate antiparasitic treatment. 1, 3 Hydrocephalus typically requires surgical intervention (ventriculoperitoneal shunt), while diffuse cerebral edema requires corticosteroids 1, 3

Adjunctive Therapies

Corticosteroid Regimens

The Infectious Diseases Society of America guidelines note that optimal corticosteroid dosing has not been clearly defined, but higher doses appear more effective 1:

• One trial comparing dexamethasone 6 mg/day for 10 days versus 8 mg/day for 28 days followed by taper noted fewer seizures in the higher-dose group 1
• Other studies have used prednisone 1-1.5 mg/kg/day during antiparasitic therapy 1
• The FDA label recommends oral or intravenous corticosteroids to prevent cerebral hypertensive episodes during the first week of treatment 2

Antiepileptic Drug Management

• Antiepileptic drugs should be used in all patients with seizures regardless of antiparasitic treatment status 1, 3
• Consider tapering antiepileptic drugs after 2 years if seizure-free and meeting criteria for withdrawal as in idiopathic epilepsy 1
• Risk factors for recurrent seizures include: (1) calcifications on follow-up CT, (2) breakthrough seizures, and (3) >2 seizures during the disease course 1

Monitoring Requirements

During Treatment

• Monitor blood counts at the beginning of each 28-day cycle and every 2 weeks while on albendazole therapy, as fatalities from granulocytopenia and pancytopenia have been reported 2
• Monitor liver enzymes (transaminases) at the beginning of each cycle and at least every 2 weeks during treatment 2
• Discontinue albendazole if clinically significant decreases in blood cell counts occur or if liver enzymes exceed twice the upper limit of normal 2

Follow-Up Imaging

• Repeat MRI at least every 6 months until complete resolution of cystic lesions to guide treatment duration and detect complications 1, 3
• Consider retreatment with antiparasitic therapy for parenchymal cystic lesions persisting for 6 months after the initial course 1

Critical Pitfalls to Avoid

• Never initiate antiparasitic therapy in patients with increased intracranial pressure, untreated hydrocephalus, or cysticercal encephalitis—this can be fatal 1, 3
• Never use antiparasitic drugs in patients with calcified parasites only—they provide no benefit and only add toxicity risk 1, 3
• Never start antiparasitic therapy without fundoscopic examination—treating patients with intraocular cysticerci can cause blindness 1, 2
• Never omit corticosteroids when using antiparasitic drugs for viable cysts—corticosteroids are associated with fewer seizures during therapy 1, 3, 2
• Always take albendazole with food—this improves absorption and bioavailability 2

Special Considerations

• Screen household members for tapeworm carriage if NCC was likely acquired in a non-endemic area, as this is a public health issue 1
• Advise females of reproductive potential to use effective contraception during albendazole treatment and for 3 days after the final dose, as albendazole causes fetal harm 2