What is the recommended treatment for Neurocysticercosis?

Treatment of Neurocysticercosis

For patients with 1-2 viable parenchymal cysts, treat with albendazole monotherapy 15 mg/kg/day (maximum 1200 mg/day) divided twice daily with food for 10-14 days; for patients with >2 viable cysts, use combination therapy with albendazole 15 mg/kg/day plus praziquantel 50 mg/kg/day for 10-14 days, always initiating corticosteroids before starting antiparasitic drugs. 1, 2

Pre-Treatment Evaluation

Before initiating any antiparasitic therapy, complete the following mandatory assessments:

• Obtain both brain MRI and non-contrast CT scan to determine the number, location, and stage of cystic lesions, as this directly determines treatment strategy 1, 3
• Perform fundoscopic examination to exclude intraocular cysticerci—treating ocular disease with antiparasitic drugs can cause irreversible retinal damage from inflammatory reactions 1, 2
• Screen for latent tuberculosis infection in patients who will require prolonged corticosteroids 1, 4
• Screen for or empirically treat Strongyloides stercoralis in patients requiring prolonged corticosteroids to prevent hyperinfection syndrome 1, 4
• Obtain pregnancy test in females of reproductive potential—albendazole is teratogenic and contraindicated in pregnancy 2

Treatment Algorithm Based on Lesion Type

Viable Parenchymal Cysts (Active Disease)

For 1-2 cysts:

• Albendazole 15 mg/kg/day divided twice daily with meals for 10-14 days (maximum 1200 mg/day) 1, 3, 2
• This monotherapy approach has strong evidence showing superiority over no treatment 1

For >2 cysts:

• Combination therapy: Albendazole 15 mg/kg/day PLUS praziquantel 50 mg/kg/day for 10-14 days 1, 4
• The 2014 randomized controlled trial demonstrated that combination therapy achieved 64% complete cyst resolution versus 37% with albendazole alone (rate ratio 1.75, p=0.014) 5
• This represents the highest quality evidence for multiple cysts and should guide practice 5

Single Enhancing Lesions (SELs)

• Albendazole 15 mg/kg/day in twice-daily doses for 1-2 weeks 1, 6
• Always combine with corticosteroids initiated prior to antiparasitic therapy 1, 6
• Antiepileptic drugs are mandatory for all patients with SELs and seizures 1, 6

Calcified Parenchymal Lesions (Inactive Disease)

• Do NOT use antiparasitic drugs—these lesions represent dead parasites and treatment provides no benefit 1, 4
• Provide symptomatic therapy only with antiepileptic drugs for seizure control 1, 4
• Corticosteroids should not be routinely used for isolated calcified lesions with perilesional edema 1

Intraventricular Cysts

• Surgical removal is preferred when technically feasible, particularly for fourth ventricular cysts 1
• If surgical removal is not possible, place ventriculoperitoneal shunt followed by antiparasitic drugs with corticosteroids to decrease shunt failure 1
• Attempted removal of inflamed or adherent ventricular cysts carries high complication risk—shunt placement is safer in these cases 1, 3

Critical Management of Elevated Intracranial Pressure

Never initiate antiparasitic therapy in patients with untreated hydrocephalus or diffuse cerebral edema:

• Manage elevated intracranial pressure FIRST with corticosteroids for diffuse edema or surgical intervention for hydrocephalus 1, 4, 6
• Antiparasitic drugs will worsen cerebral edema by causing inflammatory reactions as parasites die 1, 2
• Only after intracranial pressure is controlled should antiparasitic therapy be considered 1, 6

Mandatory Adjunctive Therapy

Corticosteroids

• Initiate corticosteroids BEFORE starting antiparasitic drugs to prevent cerebral hypertensive episodes 1, 2
• This is particularly critical during the first week of treatment 2
• The FDA label explicitly states corticosteroids should be considered to prevent cerebral hypertensive episodes 2

Antiepileptic Drugs

• All patients with neurocysticercosis and seizures require antiepileptic drugs 1, 6
• Choice should be guided by local availability, cost, and drug interactions 1
• Important caveat: Praziquantel may lower serum levels of phenytoin and carbamazepine 4
• Consider tapering antiepileptic drugs after 6 months seizure-free IF the lesion has resolved and no risk factors exist (residual cysts, calcifications, breakthrough seizures, or >2 total seizures) 1

Monitoring During Treatment

For patients on albendazole >14 days:

• Monitor complete blood count and liver enzymes at baseline and every 2 weeks 1, 2
• Albendazole can cause fatal bone marrow suppression (granulocytopenia, pancytopenia, aplastic anemia) 2
• Discontinue albendazole if clinically significant decreases in blood cell counts 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 1, 4, 6
• If cystic lesions persist at 6 months, consider retreatment with antiparasitic therapy 1

Important Drug Interactions and Dosing Details

• Albendazole must be taken with food to optimize absorption 2
• Praziquantel interacts with corticosteroids, decreasing praziquantel serum concentrations—this is why combination therapy requires careful monitoring 4
• For patients ≥60 kg: Albendazole 400 mg twice daily; for <60 kg: 15 mg/kg/day divided twice daily (maximum 800 mg/day for neurocysticercosis per FDA label) 2

Public Health Considerations

• Screen household members for tapeworm carriage if the patient likely acquired neurocysticercosis in a non-endemic area 1, 3, 4
• This prevents ongoing transmission and is typically handled by local health departments 1

Common Pitfalls to Avoid

• Never start antiparasitic drugs without first performing fundoscopic examination—ocular involvement is a contraindication due to risk of irreversible retinal damage 1, 2
• Never treat elevated intracranial pressure with antiparasitic drugs alone—this will worsen outcomes 1, 6
• Never use antiparasitic drugs for calcified lesions—they provide no benefit and only expose patients to unnecessary toxicity 1, 4
• Never forget to initiate corticosteroids before antiparasitic therapy—the inflammatory response from dying parasites can cause life-threatening cerebral edema 1, 2