Medical Care
Medical treatment of cysticercosis depends on the location of the cysts and the patient's symptoms. Patients with live parenchymal cysts can be treated with either albendazole or praziquantel, but corticosteroids and antiseizure medications are often required in addition. Consultation with a physician (neurologist or infectious diseases specialist) experienced in treating neurocysticercosis is recommended prior to planning a course of antiparasitic drug treatment. [10] Many authorities consider albendazole to be preferred over praziquantel because of its higher eradication rate of parenchymal brain cysts.
For treatment of neurocysticercosis, albendazole is orally administered at a dose of 15 mg/kg/d divided into 2 daily doses for 8-30 days (not to exceed 800 mg/d in children or 400 mg twice daily in adults). This regimen can be repeated if necessary. Praziquantel orally administered at a single dose of 5-10 mg/kg is highly effective in eradicating adult tapeworm infection. However, when this drug is used to treat neurocysticercosis, much higher doses and a longer duration of treatment is required. For neurocysticercosis, praziquantel is orally administered at a dose of 50-100 mg/kg/d divided into three daily doses for 30 days.
Patients with nonviable (calcified) brain cysts should be treated only for their symptoms; anticonvulsants are used to treat seizures. Seizures most often recur for months and may indefinitely recur. Anticonvulsant medications must be continued until cysts have resolved and until the patient is seizure free for 1-2 years.
No consensus has been reached regarding the role of antiparasitic drugs in patients with parenchymal cysts and inflammation (depicted as ring enhancement on neuroimages).
Although taeniacidal drugs that may hasten radiologic resolution of cysts are available, treatment may worsen the inflammation and, thus, precipitate complications or death.
Coadministration of corticosteroids (eg, dexamethasone, prednisone) is recommended to decrease the adverse effects of antiparasitic treatment.
In all patients with multiple cysts and associated cerebral edema (cysticercal encephalitis), antiparasitic therapy should be deferred until the cerebral edema is controlled by corticosteroid therapy. In addition, antiparasitic drug therapy may cause permanent damage if used to treat ocular or spinal cysts, even when combined with corticosteroids. A careful ocular examination to rule out ocular cysts should be performed prior to initiating antiparasitic drug treatment.
Surgical Care
For cases that do not respond to medical therapy, shunt placement, removal of large solitary cysts for decompression, and the removal of mobile cysts that cause ventricular obstruction should be considered.
Intraventricular cysts and hydrocephalus usually require surgical therapy and, often, the placement of intraventricular shunts. Adjunctive chemotherapy with antiparasitic agents and corticosteroids can reduce the rate of subsequent shunt failure.
Neuroendoscopy may be used to remove certain ventricular cysts. Spillage of cyst contents during surgery is not associated with parasite dissemination, as it is with echinococcosis. Very large cysts that cause a mass effect may require surgical debridement.
Ocular cysticercosis is treated with surgical excision of the cysts. The outcome is often poor. Thus, enucleation is frequently required. Treatment with antiparasitic drugs is contraindicated in ocular cysticercosis because the inflammatory response may worsen the outcome.
Consultations
Consultation with a neurologist should be considered to recommend anticonvulsant medications and further neurologic assessment is indicated in patients with seizures or neurologic deficits.
Consultation with a neurosurgeon may be indicated in patients with acute hydrocephalus or large intracerebral cysts with a mass effect, in those with suspected cysts in the ventricular system, or in those with spinal cysts.
Consultation with an infectious diseases or tropical medicine specialist should be considered when planning antiparasitic drug treatment in patients suspected to have live parenchymal cysts.
Consultation with an ophthalmologist to rule out intraocular cysts should be considered prior to initiating antiparasitic drug treatment.
Diet and Activity
Diet
No special diet is indicated. Good sanitation is essential to prevent the spread of the disease.
Activity
No limitations are necessary, unless activity is limited by the patient's symptoms.
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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.
