What is the recommended treatment for neurocysticercosis, including antiparasitic drug regimens, corticosteroid therapy, antiepileptic management, and indications for surgical intervention?

Treatment of Neurocysticercosis

Antiparasitic Drug Regimens

For patients with 1–2 viable parenchymal cysts, treat with albendazole monotherapy at 15 mg/kg/day (maximum 1200 mg/day) divided into 2 daily doses with food for 10–14 days. 1, 2 This regimen has strong, high-quality evidence demonstrating superiority over no treatment and provides no additional benefit when combined with praziquantel in this limited disease burden. 1

For patients with more than 2 viable parenchymal cysts, use combination therapy with albendazole 15 mg/kg/day (maximum 1200 mg/day) plus praziquantel 50 mg/kg/day divided into 3 daily doses for 10–14 days. 1, 2 This combination achieves 64% complete cyst resolution versus only 37% with albendazole monotherapy, representing strong evidence with moderate quality. 2, 3

For single enhancing lesions (SELs), albendazole 15 mg/kg/day (maximum 800 mg/day) divided into 2 doses for 1–2 weeks improves seizure outcomes based on meta-analyses with moderate-to-high quality evidence. 3, 4

Critical Dosing Error to Avoid

Do not use praziquantel 15 mg/kg/day for multiple cysts—this lower dose appears only in ineffective single-day regimens. 2 The correct dose for multiple cysts is 50 mg/kg/day divided into 3 doses. 1, 2

Mandatory Corticosteroid Therapy

Corticosteroids must be initiated before starting antiparasitic drugs in every patient to prevent inflammatory complications from parasite death. 1, 2, 3 Omitting corticosteroids markedly increases seizure risk and can cause neurological deterioration. 3

The optimal regimen is dexamethasone 8 mg/day for 28 days followed by a 2-week taper, which demonstrates the lowest seizure rate compared to shorter courses. 3, 4 An alternative is prednisone 1–1.5 mg/kg/day throughout the antiparasitic treatment period. 3

Antiepileptic Drug Management

Initiate antiepileptic drugs immediately in all patients presenting with seizures, regardless of antiparasitic treatment status. 1, 3 AEDs are the primary therapy for seizure control and should be started before addressing the parasitic infection. 3

Continue AEDs for at least 2 years after the last seizure if neuroimaging shows complete resolution of cystic lesions. 3 Discontinue AEDs only after both radiologic resolution and absence of recurrence risk factors (persistent calcifications, breakthrough seizures during therapy, or ≥2 seizures during disease course). 1, 3

Selection of specific AEDs should follow principles for remote symptomatic epilepsies, accounting for drug interactions with corticosteroids and antiparasitics. 3

Absolute Contraindications to Antiparasitic Therapy

Do not administer antiparasitic drugs if any of the following conditions are present:

• Untreated hydrocephalus 1, 3, 4
• Diffuse cerebral edema (cysticercotic encephalitis) 1, 3, 4
• Untreated intracranial hypertension 1, 3
• Only calcified lesions present (dead cysts) 3, 4

In these situations, manage elevated intracranial pressure with corticosteroids alone, as antiparasitic therapy can be fatal. 1, 3 Hydrocephalus typically requires surgical intervention with ventriculoperitoneal shunting. 1

Mandatory Pre-Treatment Assessment

Perform fundoscopic examination in all patients before initiating anthelmintic therapy to exclude intraocular cysticercosis. 1, 3, 4 Antiparasitic treatment of undetected ocular cysts can cause blindness. 3, 4

Screen for latent tuberculosis infection in patients likely to require prolonged corticosteroids. 1 Screen or provide empiric therapy for Strongyloides stercoralis in patients requiring prolonged corticosteroids to prevent hyperinfection syndrome. 1

Obtain both brain MRI and noncontrast CT scan for complete evaluation. 1 MRI is superior for detecting viable cysts, while CT better identifies calcifications. 1

Monitoring During Treatment

Monitor for hepatotoxicity and leukopenia in patients treated with albendazole for more than 14 days. 1 No additional monitoring beyond that recommended for albendazole monotherapy is needed when using combination therapy with praziquantel. 1

Repeat MRI at least every 6 months until complete resolution of the cystic component. 1, 2, 3 This follow-up imaging guides treatment duration and detects complications. 2

Consider retreatment with the same antiparasitic regimen if cystic lesions persist at 6 months after initial therapy. 1, 2, 3

Surgical Intervention Indications

Surgery is required for:

• Ventricular cysts causing obstruction 5, 6
• Hydrocephalus requiring ventriculoperitoneal shunt placement 7, 6
• Giant subarachnoid cysts causing mass effect with imminent risk of death 7
• Parenchymal lesions with refractory seizures despite medical management 6

However, intensive medical treatment with albendazole can be effective even for giant cysts (≥50 mm), potentially avoiding neurosurgery except when there is imminent risk of death. 7 In one series of 33 patients with giant subarachnoid cysts treated medically, all improved with cyst disappearance or calcification after median 59-month follow-up. 7

Special Clinical Presentations

For multiple enhancing lesions with seizures, treat initially with antiepileptic drugs, antiparasitic therapy, and corticosteroids as outlined above. 1

For cysticercus racemose without intracranial hypertension, albendazole may be effective and surgery can potentially be avoided. 6

Public Health Consideration

Screen household members for tapeworm carriage in patients who probably acquired neurocysticercosis in a nonendemic area, as this represents a public health issue often addressed by local health departments. 1