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Neuroimaging in Neurocysticercosis Treatment & Management

  • Author: Arturo Carpio, MD; Chief Editor: Niranjan N Singh, MD, DM  more...
 
Updated: Nov 12, 2014
 

Medical Care

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

Symptomatic treatment (see the image below) 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.

Treatment of Neurocysticercosis Treatment of Neurocysticercosis

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 the image below). Other authors also suggest that AED administration can be safely withdrawn once the follow-up CT scan shows resolution of the lesion.

Neuroimaging in neurocysticercosis. Antiepileptic Neuroimaging in neurocysticercosis. Antiepileptic treatment for patients with first seizure due to neurocysticercosis.

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.[8, 9] 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.[10] 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.[11] 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).[12]

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.

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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 (see the image below).

Treatment of Neurocysticercosis Treatment of Neurocysticercosis

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 the images below), should not be biopsied or removed since the parasite is dead and will disappear or be calcified spontaneously.

Neuroimaging in neurocysticercosis. CT scans showi Neuroimaging in neurocysticercosis. CT scans showing different phases of neurocysticercosis. Top left: CT scan showing many calcifications and active cysts with scolices in both hemispheres. Top right: T1-weighted MRI showing 2 active cysts with the scolex in their interior (vesicular phase). Bottom left: Postcontrast CT scan showing a ring-enhancing cyst (colloidal phase) on left. Bottom right: Proton density-weighted MRI showing a thick capsule with adjacent scolex and perilesional edema (colloidal phase).
Neuroimaging in neurocysticercosis. Noncontrast an Neuroimaging in neurocysticercosis. Noncontrast and contrast-enhanced CT scan of neurocysticercosis. Left: Normal noncontrast CT scan. Right: After administration of the contrast medium, the CT scan of the same patient shows a single parietal nodular-enhancing lesion (transitional, nodular phase).
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Contributor Information and Disclosures
Author

Arturo Carpio, MD Professor, University of Cuenca School of Medicine, Ecuador; Senior Research Scientist, 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 Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Florian P Thomas, MD, PhD, Drmed, MA, MS Director, National MS Society Multiple Sclerosis Center; Professor and Director, Clinical Research Unit, Department of Neurology, Adjunct Professor of Physical Therapy, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, Drmed, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MD, DM Associate Professor of Neurology, University of Missouri-Columbia School of Medicine

Niranjan N Singh, MD, DM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

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Neuroimaging in neurocysticercosis. CT scans showing different phases of neurocysticercosis. Top left: CT scan showing many calcifications and active cysts with scolices in both hemispheres. Top right: T1-weighted MRI showing 2 active cysts with the scolex in their interior (vesicular phase). Bottom left: Postcontrast CT scan showing a ring-enhancing cyst (colloidal phase) on left. Bottom right: Proton density-weighted MRI showing a thick capsule with adjacent scolex and perilesional edema (colloidal phase).
Neuroimaging in neurocysticercosis. Natural history of neurocysticercosis. Top left: This CT scan shows a large occipital active cyst (vesicle phase), many calcifications, and small cortical cysts. Top right: After 18 months, the occipital cyst has been replaced by a calcification and the remaining cysts have disappeared. Bottom left: A single parietal nodular-enhancing lesion (transitional, nodular-granular phase) is shown. Bottom right: Six months later, the lesion has disappeared.
Neuroimaging in neurocysticercosis. Noncontrast and contrast-enhanced CT scan of neurocysticercosis. Left: Normal noncontrast CT scan. Right: After administration of the contrast medium, the CT scan of the same patient shows a single parietal nodular-enhancing lesion (transitional, nodular phase).
Neuroimaging in neurocysticercosis. Cysticercotic encephalitis. Left: Contrast-enhanced CT scan showing multiple, small, nodular, and annular areas of abnormal enhancement in brain parenchyma. Right: Gadolinium-enhanced T1-weighted MRI showing hyperintense lesions.
Neuroimaging in neurocysticercosis. Cysticercus cellulosae in neurocysticercosis.
Treatment of Neurocysticercosis
Neuroimaging in neurocysticercosis. Cysticercus cellulosae showing the invaginated scolex in neurocysticercosis.
Neuroimaging in neurocysticercosis. Subcortical parenchymatous cysticercosis
Neuroimaging in neurocysticercosis. Inflammatory reaction in parenchymatous cysticercosis.
Neuroimaging in neurocysticercosis. Antiepileptic treatment for patients with first seizure due to neurocysticercosis.
Neuroimaging in neurocysticercosis. Probability of seizure recurrence (Kaplan-Meier curve) after a first seizure in patients with NC as function of cysticidal treatment.
 
 
 
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