Medication Summary
The goals of pharmacotherapy for neurocysticercosis are to reduce morbidity, prevent complications, and eradicate the infestation.
Medication for taeniasis is required in patients with a concomitant intestinal infection. Niclosamide is an antiparasitic medication that is not absorbed in the gastrointestinal system, which allows its concomitant use with anticysticercal treatment. However, this agent is not available in the United States.
Anticysticercal medications
Class Summary
Two medications are available in the treatment of neurocysticercosis, praziquantel (PZQ) and albendazole. [20, 21] Both agents eliminate the cysticerci or markedly reduce their number. Albendazole appears to be superior to PZQ and seems to be more effective in giant cysts [22] and subarachnoid, intraventricular, or spinal neurocysticercosis.
Use of these medications may result in further increases in intracranial pressure in patients with cysticercal encephalitis and hydrocephalus. Hence, they should be used only after a ventricular shunt has been placed in these forms of neurocysticercosis.
Drugs such as dexamethasone, phenytoin, or carbamazepine may decrease plasma levels of PZQ due to interaction with the cytochrome P-450 microsomal system. [23] This is not seen with albendazole (which is excreted unchanged in the urine). Simultaneous administration of dexamethasone appeared to increase plasma levels of albendazole and decreased its rate of elimination.
Praziquantel (Biltricide)
Praziquantel is an isoquinolone that destroys the scolex, produces paralysis of the parasite musculature, and causes extensive integumental destruction, followed by an inflammatory reaction.
Albendazole (Albenza)
Albendazole decreases ATP production in the worm, as well as inhibits polymerization of a component of the microtubules, thus preventing their formation. This causes energy depletion, immobilization, and finally death of the parasite. To avoid an inflammatory response in the central nervous system (CNS), patients also must be started on anticonvulsants and high-dose glucocorticoids.
Antiepileptics
Class Summary
In case of seizures with calcification, administration of a first-line antiepileptic drug is the most suitable treatment. In patients with viable cysts, the treatment needs to be combined with anticysticercal drugs. The use of newer antiepileptic medications (eg, valproic acid, lamotrigine, levetiracetam, topiramate, zonisamide) has not been evaluated in this particular condition, but they may be equally effective.
Phenytoin (Dilantin, Phenytek)
Phenytoin may act in the motor cortex where it may inhibit the spread of seizure activity. Activity of the brainstem centers that are responsible for the tonic phase of grand mal seizures may be also inhibited.
The dose of phenytoin should be individualized. Administer a larger dose before the patient retires to bed if the dose cannot be divided equally.
Carbamazepine (Tegretol, Carbatrol, Epitol, Equetro)
Carbamazepine is used for the management of partial seizures. This drug blocks sodium channels and inhibits high-frequency repetitive firing. Carbamazepine also acts presynaptically to decrease synaptic transmission.
Phenobarbital
Phenobarbital is useful in the treatment of partial seizures and generalized tonic-clonic seizures. This agent enhances gamma-aminobutyric acid (GABA)-mediated inhibition and reduces glutamate-mediated excitation, thereby elevating the seizure threshold and limiting the spread of seizure activity.
Glucocorticoid Agents
Class Summary
Glucocorticoid drugs are used for the management of complications due to neurocysticercosis.
Dexamethasone (Baycadron, Maxidex, Ozurdex)
Dexamethasone is a concomitant medication used for the management of reactions to anticysticercal treatment in parenchymal, subarachnoid, or spinal cysts and in the presence of vasculitis, arachnoiditis, or encephalitis.
Diuretic Agents
Class Summary
Diuretic (osmotic) drugs may reduce intracranial pressure and cerebral edema by creating an osmotic gradient across an intact blood-brain barrier. As water diffuses from the brain into the intravascular compartment, intracranial pressure decreases.
Mannitol (Osmitrol)
Mannitol may reduce subarachnoid space pressure by creating an osmotic gradient between the cerebrospinal fluid (CSF) in arachnoid space and the plasma. However, this agent is not indicated for long-term use.
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Massive nonencephalitic neurocysticercosis. Photo courtesy of Cysticercosis Working Group in Peru.
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Computed tomographic (CT) scan of the brain in a patient who presented with an episode of generalized tonic-clonic seizure. Note the calcified lesion in the left parieto-occipital region. Subsequent evaluation confirmed the diagnosis of neurocysticercosis.
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T2-weighted magnetic resonance image (MRI) of the brain showing the presence of increased signal as a result of edema in the right frontal region; subsequent studies found a cysticercus in that location.
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Magnetic resonance image (MRI) of the brain in a patient who presented with an episode of generalized tonic-clonic seizure. Note the cyst in the left parieto-occipital region with perilesional edema.
