How should a child presenting with new‑onset seizures, headache, focal neurologic deficits or signs of increased intracranial pressure and a history of pork exposure or travel to Taenia solium endemic regions be evaluated and managed for suspected neurocysticercosis?

Neurocysticercosis in Children: Evaluation and Management

Initial Diagnostic Approach

A child with new-onset seizures, headache, focal neurologic deficits, or signs of increased intracranial pressure who has pork exposure or travel to endemic regions (Latin America, sub-Saharan Africa, parts of Asia) should undergo immediate neuroimaging with both brain MRI with contrast and non-contrast CT scan, combined with serologic testing using enzyme-linked immunotransfer blot. 1

Critical History Elements

• Seizure characterization: Document whether seizures are focal, focal with secondary generalization, or generalized, as seizures occur in 70-90% of symptomatic pediatric neurocysticercosis cases 2, 3
• Geographic exposure: Specifically ask about residence in or travel to Latin America, sub-Saharan Africa, or Asia 1
• Household contacts: Identify any household members with known Taenia solium infection 1, 2
• Dietary history: Document consumption of undercooked pork 2
• Symptom timeline: Establish duration and progression, noting that symptoms typically emerge 3.5 years after infection (range up to >10 years) 1, 4
• Visual symptoms: Always ask about vision changes, as retinal involvement contraindicates antiparasitic therapy 1, 2

Essential Pre-Treatment Evaluation

Before initiating any therapy, complete the following mandatory assessments:

• Fundoscopic examination: Required to exclude ocular cysticercosis, which contraindicates anthelmintic therapy due to risk of inflammatory retinal damage 1, 4
• Stool microscopy: Examine patient and all household contacts to identify tapeworm carriers 1, 5
• Thigh radiographs: Obtain to assess for disseminated infection with calcified cysts in soft tissues 1, 4
• Strongyloides screening: Screen or provide empiric treatment before prolonged corticosteroids to prevent hyperinfection syndrome 1, 4
• Latent tuberculosis screening: Test patients likely to require prolonged corticosteroids 1

Neuroimaging Strategy

Obtain both MRI brain with contrast AND non-contrast CT scan 1, 5:

• MRI advantages: Superior for detecting scolex (pathognomonic when visualized), edema, small parenchymal lesions, posterior fossa lesions, and multiple cysts 5, 3
• CT advantages: Better for identifying calcifications, which indicate chronic/inactive disease 5
• Diagnostic finding: Visualization of scolex within cystic lesion is pathognomonic 1, 3

Treatment Algorithm by Disease Type

For Viable Parenchymal Neurocysticercosis (1-2 Cysts)

Initiate albendazole 15 mg/kg/day (maximum 800 mg/day) divided twice daily for 10-14 days, combined with corticosteroids and antiepileptic drugs 1, 5:

• Corticosteroid protocol: Start dexamethasone or prednisolone 60 mg daily one day BEFORE albendazole to prevent cerebral hypertensive episodes from inflammatory response to dying parasites 1, 4
• Antiepileptic drugs: Initiate for all patients with seizures 1, 5
• Monitoring during treatment: Check blood counts and liver enzymes at baseline and every 2 weeks during albendazole therapy 5

For Multiple Enhancing Lesions (Disseminated Disease)

Begin corticosteroids (dexamethasone or prednisolone 60 mg daily) one day before antiparasitic therapy, then albendazole 15 mg/kg/day for 8-30 days (longer courses for extensive disease) 4:

• Critical timing: Corticosteroids MUST precede antiparasitic drugs by 24 hours to prevent life-threatening cerebral edema 1, 4
• Extended duration: Disseminated disease requires longer albendazole courses than single lesions 4
• Supportive care: Monitor blood glucose and provide proton pump inhibitors for gastric protection during prolonged steroid use 1

For Untreated Hydrocephalus or Diffuse Cerebral Edema

DO NOT give antiparasitic drugs—manage elevated intracranial pressure first 1, 5:

• Hydrocephalus management: Requires surgical intervention (ventriculoperitoneal shunt or endoscopic third ventriculostomy) 1
• Cerebral edema management: High-dose corticosteroids alone without antiparasitic therapy 1
• Antiparasitic therapy: Only consider AFTER intracranial pressure is controlled 1, 5

For Single Enhancing Lesions

Albendazole monotherapy for 10-14 days reduces seizure recurrence and accelerates lesion resolution 5:

• Prognosis: Single lesions resolve in >60% of cases within 6 months with good seizure control 3
• Corticosteroids: Use concurrently to reduce inflammation 1

For Calcified Lesions Only

Antiepileptic drugs alone—antiparasitic therapy is NOT indicated for calcified lesions 1:

• Rationale: Calcifications represent dead parasites; antiparasitic drugs provide no benefit 1
• Management focus: Seizure control with antiepileptic medications 1

Follow-Up Protocol

Repeat MRI at least every 6 months until complete resolution of cystic component 1, 5:

• Antiepileptic drug tapering: Consider discontinuation after lesion resolution if no risk factors for recurrent seizures 5
• Long-term monitoring: Continue surveillance given the chronic nature of disease 5

Critical Pitfalls to Avoid

• Never skip fundoscopic examination: Retinal cysticercosis contraindicates antiparasitic therapy 1, 4
• Never give antiparasitic drugs before corticosteroids in multiple lesions: This causes potentially fatal cerebral edema 1, 4
• Never treat hydrocephalus with antiparasitic drugs first: Surgical management of elevated intracranial pressure takes priority 1, 5
• Never use antiparasitic drugs for calcified lesions: They are ineffective and unnecessary 1
• Never start prolonged steroids without Strongyloides screening: Risk of hyperinfection syndrome is fatal 1, 4
• Never use enzyme-linked immunosorbent assays with crude antigen: Poor sensitivity and specificity make them unreliable 1

Special Considerations in Children

Neurocysticercosis is the most common cause of focal-onset seizures in North Indian children and a major cause of epilepsy in tropical areas 6, 3. The disease has pleomorphic manifestations in children depending on cyst location, number, viability, and host immune response 6, 3. Prognosis is generally favorable for single parenchymal lesions but guarded for cysticercus encephalitis, racemose, and extraparenchymal disease 3.