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 critical caveat that antiparasitic drugs are contraindicated in patients with elevated intracranial pressure or cysticercal encephalitis where they increase mortality. 1

Pre-Treatment Assessment

Before initiating any therapy, perform these mandatory evaluations:

• 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, 2
• Perform fundoscopic examination to exclude intraocular cysticerci, as antiparasitic treatment may cause blindness in patients with retinal involvement 1, 3, 4
• Assess for elevated intracranial pressure or hydrocephalus, as these are absolute contraindications to antiparasitic therapy 1, 3
• Screen for latent tuberculosis and Strongyloides stercoralis if prolonged corticosteroids are anticipated 1, 2
• Obtain pregnancy test in females of reproductive potential, as albendazole causes fetal harm 4

Treatment Algorithm Based on Disease Stage

Viable Parenchymal Cysts (1-2 cysts)

Use albendazole monotherapy:

• Albendazole 15 mg/kg/day in 2 divided doses (maximum 1200 mg/day) with food for 10-14 days 1
• Combination therapy shows no additional benefit with 1-2 cysts and adds unnecessary complexity 1

Viable Parenchymal Cysts (>2 cysts)

Use combination antiparasitic therapy:

• Albendazole 15 mg/kg/day in 2 divided doses (maximum 1200 mg/day) PLUS praziquantel 50 mg/kg/day in 3 divided doses for 10-14 days 1
• Pharmacokinetic studies and randomized trials demonstrate superior radiologic resolution with combination therapy compared to albendazole alone when >2 cysts are present 1
• A recent African study showed 95% cyst resolution with combination therapy after albendazole monotherapy achieved only 42% resolution 5

Single Enhancing Lesion

Use shorter course albendazole:

• Albendazole 15 mg/kg/day in 2 divided doses (maximum 800 mg/day) for 1-2 weeks 1, 2
• Meta-analyses demonstrate improved seizure outcomes with albendazole treatment 1

Calcified Parenchymal Cysts

Do NOT use antiparasitic therapy:

• No viable cysts present, therefore no indication for antiparasitic drugs 1, 3
• Treat only with antiepileptic drugs for seizure control 1

Cysticercal Encephalitis (Diffuse Cerebral Edema)

AVOID antiparasitic drugs entirely:

• Treat with corticosteroids alone for diffuse cerebral edema 1, 3
• Antiparasitic drugs are associated with worsening edema and increased mortality in this setting 1, 3
• This is a critical pitfall that can be fatal if missed 3, 2

Untreated Hydrocephalus

Manage elevated intracranial pressure first:

• Antiparasitic treatment is contraindicated until hydrocephalus is addressed 1, 3, 2
• Hydrocephalus typically requires surgical intervention (shunt placement) before considering antiparasitic therapy 1, 3

Mandatory Adjunctive Therapies

Corticosteroids (Essential with Antiparasitic Drugs)

Corticosteroids must be used whenever antiparasitic drugs are administered:

• Adjuvant corticosteroids are associated with fewer seizures during therapy 1, 3
• Oral or intravenous corticosteroids should be given concomitantly to prevent cerebral hypertensive episodes during the first week of treatment 1, 3, 4
• While optimal doses are not clearly defined, one trial showed fewer seizures with dexamethasone 8 mg/day for 28 days followed by taper compared to 6 mg/day for 10 days 1
• Other studies have used prednisone 1-1.5 mg/kg/day during therapy 1

Antiepileptic Drugs

All patients with seizures require antiepileptic drugs:

• Antiepileptic drugs should be used in all patients with neurocysticercosis who present with seizures, regardless of antiparasitic treatment status 1, 3, 2
• Consider tapering antiepileptic drugs after 2 years if seizure-free and cystic lesions have resolved, provided no risk factors for recurrence are present 1, 2
• Risk factors for recurrent seizures include: (1) calcifications on follow-up CT, (2) breakthrough seizures, and (3) >2 seizures during disease course 1

Monitoring During Treatment

Monitor for toxicity with the following schedule:

• Blood counts at the beginning of each 28-day cycle and every 2 weeks during therapy to detect bone marrow suppression 1, 4
• Liver enzymes (transaminases) at the beginning of each cycle and at least every 2 weeks during treatment 1, 4
• Patients with liver disease are at increased risk for bone marrow suppression and warrant more frequent monitoring 4
• Discontinue albendazole if clinically significant decreases in blood cell counts occur 4

Follow-Up Imaging

Repeat MRI at least every 6 months until complete resolution of cystic lesions:

• This guides treatment duration and detects complications 1, 3, 2
• Consider retreatment with antiparasitic therapy for parenchymal cystic lesions persisting for 6 months after the initial course 1

Surgical Intervention

Surgery is indicated for specific anatomical complications:

• Fourth ventricular cysticerci where surgical removal is technically feasible—surgical excision is superior to medical therapy in preventing mortality from obstructive hydrocephalus 3
• Ventricular cysts may benefit from medical therapy, but surgery remains the current standard approach 6

Critical Pitfalls to Avoid

• Never initiate antiparasitic therapy in patients with cysticercal encephalitis or uncontrolled intracranial hypertension—this can be fatal 3, 2
• Never use antiparasitic drugs in patients with calcified parasites only—they provide no benefit and only add toxicity risk 3
• Never start antiparasitic drugs without concomitant corticosteroids (except in calcified disease where neither is indicated) 1, 3
• Never begin antiparasitic treatment without fundoscopic examination to exclude intraocular involvement 1, 3, 4

Public Health Consideration

Screen household members for tapeworm carriage if the patient likely acquired neurocysticercosis in a non-endemic area, as this is a public health issue often addressed by local health departments 1, 2