Cysticercosis Treatment & Management

Updated: Oct 05, 2015
  • Author: Mossammat M Mansur, MD, MBBS; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Treatment

Medical Care

Asymptomatic cysticercosis: As mentioned above, more than 80% of patients with cysticercosis are asymptomatic. No evidence has shown that administering antiparasitic therapy for asymptomatic nonviable cysticercal lesions found incidentally in the brain is beneficial.

Patients who are found to have cysticerci only in subcutaneous or intramuscular sites generally do not require specific therapy.

If a single extracranial lesion is found, excision can be considered after neurocysticercosis is excluded with brain imaging.

Patients with ocular cysticercosis who have extraocular muscle involvement may present with diplopia and recurrent eye pain. Treatment with albendazole and corticosteroids has proven to be beneficial. Some patients may require surgical excision. In patients with intraocular cysticercosis, vitreoretinal surgery (either transscleral or transvitreal) can be performed to remove the cysticerci.

Patients with subcutaneous or intramuscular cysticercosis who develop symptoms due to inflammation can be treated with cysticerci excision or anti-inflammatory agents. Excision is the treatment of choice for a solitary symptomatic lesion.

Symptomatic therapy is the mainstay of treatment for neurocysticercosis, as follows:

  • Anticonvulsants are prescribed to patients with seizures.
  • Specific anthelminthic therapy with albendazole or praziquantel is prescribed, usually accompanied by corticosteroids.
  • Corticosteroids are used in patients with cerebral edema or vasculitis.
  • CSF diversion is instituted in patients with obstructive hydrocephalus.

Parenchymal disease should be treated medically, as follows:

  • The primary focus is symptomatic therapy for seizures.
  • A postictal patient should initially receive supportive care that includes a safe environment.
  • Anticonvulsants should be administered early but may be tapered when seizures are controlled if findings from neuroimaging studies revert to normal (see Medication).
  • If significant intracranial edema is demonstrated, corticosteroids should be administered before antiparasitic therapy is considered. Some authorities recommend routine use of corticosteroids in all cases of active neurocysticercosis.
  • If viable cysticerci are suspected, antiparasitic drugs (ie, praziquantel and albendazole) may be used to hasten the death of the parasite.
  • A prospective randomized study compared the use of antiparasitic agents with placebo in patients with active parenchymal lesions. Results showed no significant difference in the number of subjects with recurrent seizures. However, the number of generalized seizures was significantly reduced with the combination of steroids and antiparasitic drugs. The beneficial effect was seen in a subgroup of subjects with numerous recurrent seizures. [15]
  • Patients with only calcifications (ie, residual phase) with or without edema do not need antiparasitic therapy.
  • Patients with cerebral edema or uncontrolled hydrocephalus should not be treated with antiparasitic therapy until these conditions are resolved.
  • Patients with multiple cysticerci, especially in the basilar cisterns, or with giant cysticerci of the sylvian fissures, should receive both corticosteroids and antiparasitic therapy.
  • Generally, ventricular disease should be treated surgically, preferably via an endoscopic approach. However, if the surgery is being performed only to place a shunt and not to remove the cysts, antiparasitic therapy should be administered after the shunting procedure.
  • Neuroendoscopy provides a safe and minimally invasive procedure for the removal of symptomatic cysts, minimizing morbidity and mortality relating to the natural history of the disease, as well as possibly avoiding a more extensive standard open craniotomy. The endoscopic approach can be made via transventricular corridor, perforating overlying structures such as the septum pellucidum. In some cases, burr holes may be required.
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Surgical Care

See the list below:

  • Surgical procedures are required in some patients based on complicating factors, such as hydrocephalus or giant cysts (>10 cm) in the setting of intracranial hypertension.
  • Surgical intervention should also be considered if a cyst is found in the fourth ventricle, is attached to the middle cerebral artery (MCA), or is compressing the optic chiasma.
  • Extraparenchymal disease was once treated surgically by placing a shunt because most symptoms are due to hydrocephalus.
  • Surgical resection of ventricular neurocysticercosis is associated with a low long-term risk of postoperative morbidity.
  • Some studies suggest that endoscopic removal may be able to replace open surgery for removal of cysticerci in most cases.
  • Ventriculoperitoneal (VP) shunting is now commonly used for the treatment of hydrocephalus. Case series have shown that the cysticerci are usually ruptured during removal, but no adverse consequences have been noted.
    • In patients with viable cysticerci, the use of VP shunt alone results in treatment failure in almost 75% of cases. [16] The use of antiparasitic drugs and corticosteroids in conjunction with VP shunt placement improve the outcome.
    • Although recurrent blockage of shunts is very common, it is unclear whether antiparasitic therapy or long-term corticosteroid treatment decreases the risk of shunt blockage and malfunction.
    • Recent descriptions of valveless shunts noted lower rates of recurrent hydrocephalus, but these shunts were associated with a higher rate of inadequate drainage.
  • Patients with inactive disease may present with hydrocephalus due to scar tissue in the cisterns or ventricular space, without evidence of cystic lesions.
    • VP shunting is necessary in these cases.
    • Antiparasitic drugs and corticosteroids are not needed because the cysticerci have already degenerated and shunt failure is rare.
  • Neurocysticercosis of the basilar cisterns should be treated with corticosteroids, prolonged courses (eg, months) of antiparasitic drugs, and VP shunting if hydrocephalus is present.
  • Giant subarachnoid cysticerci can cause significant mass effect as associated edema. The edema may respond to steroids, but the mass effect may remain.
    • Surgical drainage may be necessary.
    • Antiparasitic drugs may be beneficial, but only after steroids are given.
  • Generally, ocular and spinal medullary cysticerci should be removed surgically.
    • However, cures of spinal medullary disease have been reported with medical treatment including corticosteroids and antiparasitic drugs.
    • Antiparasitic treatment in patients with retinal cysticerci may cause irreversible retinal damage.
  • Spinal subarachnoid disease can often be treated medically.
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Consultations

Consultation with a neurosurgeon is essential in patients with hydrocephalus, significant mass effect, or extraparenchymal CNS disease.

Consultation with a neurologist is needed if protracted or refractory seizures occur.

Consultation with an infectious disease specialist is recommended if active disease is suspected.

An ophthalmologist should be consulted for patients with ocular neurocysticercosis. At a minimum, a funduscopic examination should be performed before the initiation of antiparasitic drug therapy.

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Diet

No specific diet restriction is recommended.

Patients should avoid reinfection and reingestion of ova from original sources by observing the following guidelines:

  • Inspection of pork for cysticerci, which are visible in raw meat ("measly meat")
  • Freezing or adequately cooking meat to destroy cysticerci (Pickling and salting are inadequate.)
  • Administering antiparasitic agents to pigs
  • Good personal hygiene and hand-washing prior to food preparation
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Activity

No activities are restricted if the patient is otherwise asymptomatic.

All patients who present with seizures should take seizure precautions. Patients with a history of seizures may have state-required restrictions on driving motor vehicles. Physicians may be responsible for informing patients about these restrictions.

Patients with hydrocephalus may have ataxia and may be at risk for falls.

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