Medication Summary
Specific recommendations for treatment of neurocysticercosis remain controversial. Treatment depends on disease presentation. Observation, symptomatic treatment, antiparasitic treatment, and/or surgery may play a role.
Medical therapy may include antihelminthic medications (to reduce cysts) or anticonvulsant medications. Antihelminthic medications work only in noncalcified lesions and may not decrease long-term morbidity associated with cysticercosis. Initially, they may worsen the patient's condition because of the inflammatory response to the dying or dead cyst. Additionally, medical therapy may convert quiescent parenchymal lesions to active ones or may worsen ventricular, ocular, or spinal disease. Corticosteroids should be started 2-3 days before the initiation of antihelminthic drugs and continued during their use to decrease the inflammatory response to the dying cysts. In cases with evidence of hydrocephalus or ventricular or spinal disease, a ventricular shunt should be placed before medical therapy is initiated.
If one drug is not successful, a second drug may be used in a sequential manner. This treatment may eliminate more than 95% of the parenchymal cysticerci.
Albendazole is the drug of choice. Repeated courses of albendazole have been shown to be of benefit in patients who had a positive response to an initial course. Therapy for 1 week may be as beneficial as a 4-week course of therapy.
Antihelminthic agents
Class Summary
These are used to eradicate cysts in noncalcified brain lesions. Parasite biochemical pathways are different from those of the human host; thus, toxicity is directed to the parasite, egg, or larvae. The mechanism of action varies within the drug class. Antiparasitic actions may include the following:
- Inhibition of microtubules, which causes irreversible block of glucose uptake
- Inhibition of tubulin polymerization
- Depolarizing neuromuscular blockade
- Cholinesterase inhibition
- Increased cell membrane permeability, which results in intracellular calcium loss
- Vacuolization of the schistosome tegument
- Increased cell membrane permeability to chloride ions caused by alternations in the chloride channels
Albendazole (Albenza)
Broad-spectrum antihelminthic. It is cysticidal and destroys approximately 85% with a single course. Administer for 8-30 d with a fatty meal to improve absorption.
Praziquantel (Biltricide)
Cysticidal agent that destroys approximately 75% of cysts with a single course. Increases cell membrane permeability in susceptible worms, resulting in loss of intracellular calcium, massive contractions, and paralysis of musculature. Causes vacuolization and disintegration of the schistosome tegument, followed by attachment of phagocytes to the parasite and death. Tabs should be swallowed whole with some liquid during meals. Bitter taste can cause nausea or vomiting if tabs are held in the mouth.
Niclosamide (Niclocide)
Used in the treatment of adult worms. No longer commercially available in the United States. Not absorbed and does not provoke an inflammatory response to cysticerci. Inhibits mitochondrial oxidative phosphorylation and glucose uptake in the parasite.
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Cysticercosis life cycle. Image courtesy of the Centers for Disease Control and Prevention.
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MRI of 6-year-old boy from Peru with single right frontal cyst (coronal image). Image courtesy of Eric H. Kossoff, MD.
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Axial image MRI of same patient as in Media file 2. Image courtesy of Eric H. Kossoff, MD.
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CT scan of intraparenchymal cysticercosis with lesions in different stages. Lesions that are breaking down demonstrate peripheral enhancement after intravenous contrast injection, whereas lesions without peripheral enhancement are intact. Typical residual calcification from an old focus of infection is observed in the left occipital lobe. Image courtesy of Fred Greensite, MD.
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Racemose (extraparenchymal) cysticercosis (T1-weighted MRI). Note the cyst in the fourth ventricle, causing obstructive hydrocephalus. Image courtesy of Fred Greensite, MD.
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Racemose cysticercosis (T1-weighted MRI). Note cluster of cysts anterior to the pons and inferior to the hypothalamus in a different patient. Image courtesy of Fred Greensite, MD.
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Racemose cysticercosis (same patient as in Media file 6). Note the enhancing margin of the cysts in the suprasellar cistern and in the left sylvian fissure after gadolinium injection (T1-weighted MRI). Image courtesy of Fred Greensite, MD.
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Racemose cysticercosis (same patient as in Media files 6-7). Coronal image (postgadolinium T1-weighted MRI) posterior to the slice in Media file 7. Cysts in this slice (below the hypothalamus) do not have enhancing margins. Also, unlike intraparenchymal lesions, scolexes are typically not identified in the cysts of racemose cysticercosis. Image courtesy of Fred Greensite, MD.
