Approach Considerations
Treatment of neurocysticercosis depends upon the viability of the cyst and its complications. [5] Management includes symptomatic treatment as well as treatment directed against the parasite. [18]
Dead Parasite
If the parasite is dead, the treatment is directed primarily against the symptoms (eg, anticonvulsants for management of seizures). Monotherapy is usually sufficient. Duration of the treatment remains undefined, and depends neither on the type of seizure at presentation nor on other risk factors for recurrence, such as age at onset and number of seizures before diagnosis. Calcification remains an epileptogenic focus. Treating patients with viable cysts with a course of anticysticercal drugs in order to achieve better control of seizures is common practice.
Viable or Active Parasite
If the parasite is viable or active and the patient has vasculitis, arachnoiditis, or encephalitis, a course of steroids or immunosuppressants is recommended before the use of anticysticercal drugs. Antiparasitic treatment [6] with albendazole is also useful in cysticercosis of the racemose type.
If only parenchymal, subarachnoid, or spinal cysts are present without the complications mentioned previously (eg, chronic epilepsy, headaches, neurologic deficits related to strokes, and hydrocephalus), anticysticercal treatment can be considered, with the concomitant use of steroids, even in patients with massive brain infection. Reports indicate that multiple trials with anticysticercal treatment may be required for giant subarachnoid cysts.
Guidelines issued in April 2013 by the American Academy of Neurology recommend use of albendazole plus a corticosteroid for the treatment of parenchymal neurocysticercosis. [1] The guideline, which is also endorsed by the American Epilepsy Society, recommends treatment with albendazole (400 mg twice daily for adults or weight-based dosing for either adults or children) plus either dexamethasone or prednisolone to decrease the number of active lesions on brain imaging studies and reduce long-term seizure frequency. [2]
A double-blind, placebo-controlled study showed that in patients with seizures due to viable parenchymal cysts, antiparasitic therapy decreases the burden of parasites and is safe and effective, at least in reducing the number of seizures with generalization. [7]
Surgical Intervention
In the presence of hydrocephalus due to an intraventricular cyst, placement of a ventricular shunt is recommended, followed by surgical extirpation of the cyst and subsequent medical treatment. [8]
In cases of multiple cysts in the subarachnoid space (ie, the racemose form), surgical extirpation, on an urgent basis, is recommended. If the obstruction is due to arachnoiditis, placement of a ventricular shunt should be followed by administration of steroids and subsequent medical therapy.
Because of frequent shunt dysfunctions due to entry of inflammatory tissue as well as parasitic debris inside the ventricular cavities, Sotelo designed a device that functions at a constant flow without the valvular mechanism of Pudenz-type shunts.
Surgical treatment in the particular case of medically refractory epilepsy due to a single lesion has been reported. Evaluation in an epilepsy center is indicated.
Neuroendoscopy is a tool with great potential for use in the management of ventricular cysticercosis.
Most patients with ocular or spinal lesions require surgical management. [19]
Long-Term Monitoring
Intracerebral cysticercotic lesions can cause epilepsy in the future. Administration of antiepileptic medication is the same as in any other epileptic syndrome.
Follow-up imaging study is recommended after 2-3 months following treatment, especially in cases in which anticysticercal medications are used as a diagnostic tool. The use of imaging will guide the requirement of future trials of anticysticercal medication in cases of subarachnoid cysticercosis.
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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.
