eMedicine Specialties > Neurology > Neurological Infections

Neuroimaging in Neurocysticercosis: Treatment & Medication

Author: Arturo Carpio, MD, Director of Epilepsy Center, Professor, Department of Neurology, University of Cuenca School of Medicine, Ecuador; Senior Research Scientist of the GH Sergievsky Center, Columbia University
Coauthor(s): Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Contributor Information and Disclosures

Updated: Jul 10, 2009

Treatment

Medical Care

Because of the variable clinical course of neurocysticercosis (NC), treatment must be individualized for each patient.

  • Symptomatic treatment (Media file 6) includes corticosteroids for intracranial edema and inflammation, antiepileptic drugs for secondary acquired epilepsy, analgesic medication for headache, and osmotic agents such as mannitol or glycerol for intracranial hypertension.
  • Antiepileptic treatment
    • First seizures due to inflamed cysticercal lesions should be considered acute symptomatic seizures. Therefore, they should be treated only for the duration of the acute condition. However, treatment may be continued during the period when the inflammatory response is active, which might last several months.
    • No guidelines exist for the time for which antiepileptic drugs (AED) should be continued following an acute neurocysticercosis episode. The risk of seizures is substantial as long as an active ongoing process, as characterized by persistence of edema around the degenerating lesion, is present. Because of this risk, CT scans are useful for treatment decisions.
    • Seizures in the context of edema and a degenerative lesion should be considered acute symptomatic seizures, even if they occur many months after presentation. After resolution of the acute lesion, AED administration may be discontinued.
    • Seizures occurring after resolution of edema or calcification of the degenerating cyst should be considered unprovoked, and, in this situation, long-term AED administration is warranted (see Media file 10). Other authors also suggest that AED administration can be safely withdrawn once the follow-up CT scan shows resolution of the lesion.
  • Cysticidal treatment
    • Clinical controversy has centered on the role of cysticidal agents for the treatment of symptomatic NC. Cysticidal agents in current use for NC include praziquantel and albendazole.11,22 Cysticidal therapy may hasten radiologic resolution of cysts but can be associated with exacerbation of neurologic symptoms; the possibility exists of massive cerebral edema and death in some individuals who have multiple cysts.
    • Some authors have advocated simultaneous administration of steroids to reduce the inflammatory response and exacerbation of symptoms, but the safety of this treatment has not been evaluated fully. In developing countries, most neurologists administer the steroids and cysticidal drugs at the same time.
    • Patients with NC are possibly more likely to remain seizure-free if cysticidal treatment is administered; however, recent studies have shown that there is no correlation between treatment with cysticidal drugs and seizure recurrence.
    • A meta-analysis of randomized trials assessing the effect of cysticidal drugs (albendazole and praziquantel) on neuroimaging and clinical outcomes of patients with NC has been reported.13  
      • The search identified 764 papers, of which only 11 met the inclusion criteria, from which 5 were qualified as “good quality.” Among these 5 studies, just 2 were carried out on patients with active or viable cysts, and the remaining 3 studies were performed on transitional or degenerative cysts, in which the parasite is already dead and therefore the treatment with cysticidal drugs is probably worthless.
      • The effects of treatment on neuroimaging end points were relatively small (odds ratios > 2.2). The editors of this paper concluded that the 11 selected studies were small and heterogeneous and provided limited evidence of a modest effect of cysticidal treatment in patients with NC.
    • During the last few years, 2 double-blind, randomized, placebo-controlled trials to evaluate the effects of cysticidal treatment (albendazole) in patients with NC have been published.
      • Garcia et al concluded that antiparasitic therapy in patients with viable parenchymal cysts is safe and effective; however, 6 months after treatment, only 38% of patients had cysts that disappeared on neuroimaging in comparison with 15% of patients who used placebo.18
      • Carpio et al reported disappearance of cysts in 35% of patients with viable cysts in comparison with 12% of the placebo group. In both studies, these differences were statistically significant (p <0.05).7
      • Based on these 2 studies, cysticidal treatment using albendazole is effective in terms of disappearance of viable parenchymal cysts in one third of patients.
      • The study of Carpio et al found a reduction in the number of active extraparenchymal cysts (intraventricular and subarachnoideal) in the albendazole group compared with the placebo group, although it was not statistically significant.
  • No definitive data exist pertaining to combination antihelminthic therapy or whether the use of steroids increases or decreases antihelminthic dosage requirements.

Surgical Care

  • Surgical treatment should be restricted to removal of the parasite located in the subarachnoid (racemose form) or ventricular area, and to ventriculoperitoneal shunting for the treatment of decompensated hydrocephalus (Media file 6).
  • Surgery should not be considered for parenchymal cysts without regard to location, size, or stage of evolution, because this form of NC can be controlled only by symptomatic treatment (or presumably by etiologic treatment). In addition, surgical sequelae could result in more brain damage than the parasite itself.
  • Transitional or degenerative cysts, regardless of their size or location (see Media file 1 and Media file 3), should not be biopsied or removed since the parasite is dead and will disappear or be calcified spontaneously.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Anthelmintics

Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.


Albendazole (Albenza)

Broad-spectrum agent that chemically belongs to benzimidazole group. Has been used to treat enterobiasis, ascariasis, trichuriasis, strongyloidiasis, and hookworm infections, but in US, approved only for use in hydatid disease and neurocysticercosis. Inhibits parasite's ability to assemble tubulin dimers into tubulin polymers, thus arresting microtubule formation. This affects several aspects of parasite's life, including larval development, carbohydrate transport, and enzyme function, as well as maintenance of parasite integument and digestive system.

Adult

15 mg/kg/d PO for 8 d; longer treatment period seems unnecessary

Pediatric

< 2 years: 200 mg/d PO for 3 d and repeat in 3 wk, if necessary
> 2 years: Administer as in adults

Carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity; theophylline levels not altered by single dose of albendazole, but recommended that levels be followed if used concurrently

Documented hypersensitivity; ocular cysticercosis

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Teratogenic in animals and should not be used in pregnant women unless potential benefit justifies risk to fetus; women of childbearing age should begin treatment only after negative pregnancy test; if patient becomes pregnant while taking drug, discontinue use immediately; because of potential toxicity to liver and bone marrow, routine monitoring (CBCs and LFTs) should be performed every 2 wk
Few severe dose-related adverse effects associated with drug; most symptoms experienced (eg, headaches) related to underlying condition being treated; GI upset reported in 40% of patients; transient WBC reduction and hepatic enzyme elevation reported in association with drug; rare occurrences of granulocytopenia and hepatotoxicity reported


Praziquantel (Biltricide)

Effective against various trematodes and cestodes including Schistosoma species and tapeworms. Works by increasing parasite's cell membrane permeability. Results in loss of intracellular calcium, massive muscle contractions, and spastic paralysis of parasites, as well as damage to schistosome tegument, followed by attachment of phagocytes to parasite.

Adult

50 mg/kg/d PO for 2 wk

Pediatric

< 4 years: Not established
> 4 years: Administer as in adults

Hydantoins may reduce serum concentrations, possibly leading to treatment failures; dosage adjustment may be needed with concomitant steroid use

Documented hypersensitivity; ocular cysticercosis; lactation

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse reactions associated with use include malaise, GI discomfort, headache, and dizziness; malaise, drowsiness also may be seen; rarely, fever and urticaria are seen; adverse effects may be due to helminthic infection itself; destruction of parasite within eyes can cause irreparable lesions (ocular cysticercosis should not be treated with praziquantel); caution while driving or performing other tasks requiring alertness on day of and following treatment; minimal increases in liver enzymes reported; when schistosomiasis or fluke infection associated with cerebral cysticercosis, hospitalize patient for duration of treatment

More on Neuroimaging in Neurocysticercosis

Overview: Neuroimaging in Neurocysticercosis
Differential Diagnoses & Workup: Neuroimaging in Neurocysticercosis
Treatment & Medication: Neuroimaging in Neurocysticercosis
Follow-up: Neuroimaging in Neurocysticercosis
Multimedia: Neuroimaging in Neurocysticercosis
References
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Further Reading

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Keywords

neurocysticercosis, pork tapeworm, taeniasis, Taenia solium, T solium, cysticercosis, imaging studies, antihelminthic treatment, parasite, parasitic infection

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Contributor Information and Disclosures

Author

Arturo Carpio, MD, Director of Epilepsy Center, Professor, Department of Neurology, University of Cuenca School of Medicine, Ecuador; Senior Research Scientist of the GH Sergievsky Center, Columbia University
Arturo Carpio, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Medical Editor

Joseph F Hulihan, MD, Vice President, Medical Affairs, Ortho-McNeil Janssen Scientific Affairs, LLC
Joseph F Hulihan, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Headache Society, and American Medical Association
Disclosure: Johnson & Johnson Salary Employment; Johnson & Johnson Stock Employment

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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