What are the immediate steps for a patient presenting with NCC (Neurological Condition or Complaint)?

Immediate Management of Neurocysticercosis (NCC)

For patients presenting with suspected NCC, immediately assess for seizures and signs of increased intracranial pressure, obtain urgent neuroimaging with MRI (preferred) or CT, and initiate antiepileptic drugs if seizures are present while deferring antiparasitic therapy until hydrocephalus and diffuse cerebral edema are excluded. 1

Initial Clinical Assessment

Priority Symptoms to Identify

• Seizures (focal, focal with generalization, or generalized) are the most common presentation, occurring in approximately 29% of cases in endemic areas 1
• Signs of increased intracranial pressure: headache, nausea, vomiting, altered mental status, papilledema 1
• Neurological deficits: focal weakness, visual changes, spinal radiculopathies 1
• Fever is typically absent in NCC, which helps distinguish it from other CNS infections 1

Critical Exposure History

• Query about lifetime exposure to tapeworm carriers, not just recent travel, as the latent period averages 3.5 years and may exceed 10 years 1
• Ask specifically about access to safe water, improved sanitation, contact with pork-raising areas, and consumption of undercooked pork 1
• Investigate household contacts for potential tapeworm carriage 2

Immediate Diagnostic Workup

Neuroimaging (First Priority)

• MRI with contrast is strongly preferred over CT for superior characterization of cystic lesions, edema, and treatment response 1, 3
• Non-contrast CT can be used if MRI is unavailable but underestimates disease extent 3
• Obtain imaging urgently to identify: viable parenchymal cysticerci, ventricular involvement, hydrocephalus, or diffuse cerebral edema 1

Pre-Treatment Mandatory Evaluations

• Fundoscopic examination to rule out retinal cysticercosis before starting anthelmintics 1, 2
• Stool microscopy on patient and all household contacts to identify intestinal tapeworm infection 1
• Screen for Strongyloides stercoralis in patients likely requiring prolonged corticosteroids 2
• Screen for latent tuberculosis if prolonged corticosteroids anticipated 2

Confirmatory Testing

• Enzyme-linked immunotransfer blot is the recommended serologic test 1, 2
• Avoid ELISA using crude antigen due to poor sensitivity and specificity 1

Immediate Treatment Decisions

DO NOT START ANTIPARASITIC THERAPY IF:

• Untreated hydrocephalus is present - requires surgical management first 1
• Diffuse cerebral edema is present - requires corticosteroids alone initially 1
• These conditions require management of elevated intracranial pressure before considering antiparasitic drugs 1

Immediate Seizure Management

• Start antiepileptic drugs immediately for all NCC patients presenting with seizures 1
• Choice of antiepileptic drug should be guided by local availability, cost, drug interactions, and side effects 1
• Continue antiepileptic drugs throughout antiparasitic treatment 1

Corticosteroid Initiation (When Appropriate)

• Begin corticosteroids one day before starting antiparasitic therapy to prevent inflammatory complications 1
• Recommended regimen: dexamethasone or prednisolone 60 mg once daily for 14 days, then wean according to local guidance 1
• Monitor blood glucose and provide gastric protection with proton pump inhibitors 1

Antiparasitic Treatment Algorithm (After Excluding Contraindications)

For 1-2 Viable Parenchymal Cysticerci:

• Albendazole monotherapy: 15 mg/kg/day divided into 2 daily doses for 10-14 days (maximum 1200 mg/day) 1, 2
• Take with food to enhance absorption 1

For >2 Viable Parenchymal Cysticerci:

• Combination therapy: Albendazole 15 mg/kg/day PLUS Praziquantel 50 mg/kg/day for 10-14 days 1, 2
• This combination is superior to monotherapy for multiple lesions 1

Monitoring During Treatment:

• Monitor blood counts at baseline and every 2 weeks while on albendazole for hepatotoxicity and leukopenia 1, 2
• No additional monitoring needed for combination therapy beyond albendazole monitoring 1

Critical Pitfalls to Avoid

• Do NOT obtain imaging during the first 2-3 weeks of treatment unless clinical deterioration occurs, as inflammatory changes are expected 3
• Do NOT use praziquantel for intestinal T. solium tapeworm until neurocysticercosis is excluded, as it can worsen neurological symptoms 4
• Do NOT start antiparasitic therapy before initiating corticosteroids, as this increases risk of severe inflammatory reactions 1
• Do NOT discharge patients with acute NCC until seizures are controlled and elevated intracranial pressure is managed 1

Follow-Up Imaging Timeline

• First follow-up MRI at 3 months after completion of antiparasitic therapy 3
• Repeat MRI every 6 months until complete resolution of cystic component 1, 3
• Obtain urgent imaging for new neurological symptoms, worsening headache, or clinical deterioration during steroid taper 3