Table 2.
Summary of Treatment Recommendations for Different Forms of Parenchymal Neurocysticercosis
| Form | Type of Therapy/Subgroup | Recommendation | Comment | Strength of Recommendation; Quality of Evidence |
|---|---|---|---|---|
| Viable parenchymal | Antiparasitic therapy | Antiparasitic drugs should be used in all patients with viable parenchymal NCC unless there is increased intracranial pressure. | The preponderance of studies demonstrated more rapid radiologic resolution in patients treated with antiparasitic drugs compared with placebo and decreased numbers of generalized seizuresa. | Strong; moderate |
| 1–2 viable cysts | Monotherapy with albendazole (15 mg/kg/d in 2 daily doses up to 1200 mg/d) with food for 10 d. | Combination therapy showed no additional benefit with 1 or 2 cysts and more complex pharmacologyb. | Strong; moderate | |
| >2 viable cysts | Albendazole (15 mg/kg/d in 2 daily doses up to 1200 mg/d) combined with praziquantel (15 mg/kg/d in 3 daily doses) for 10 d. | Both the pharmacokinetic study and a recent randomized trial demonstrated improved radiologic resolution with the combination compared to albendazole alone in those with >2 cysticercib. | Strong; moderate | |
| Anti-inflammatory therapy | Corticosteroids should be used whenever antiparasitic drugs are used. | Adjuvant use of corticosteroids is associated with fewer seizures during therapy Optimal doses have not been clearly definedc. | Strong; moderate | |
| Antiepileptic therapy | Antiepileptic drugs should be used in all patients with seizures. | Antiepileptic drugs appear to be effective in controlling seizures in patients with parenchymal NCC; consider tapering off after 2 years if meet criteria for withdrawal as in idiopathic epilepsyd. | Strong; moderate | |
| Single enhancing lesion due to neurocysticercosis | Antiparasitic therapy | Albendazole (15 mg/kg/d in 2 daily doses up to 800 mg/d) for 1–2 wk. | Albendazole shown to improve seizure outcome in meta-analysese. Different studies have employed a range of durations of treatment without clear advantages of longer duration. | Weak; high |
| Anti-inflammatory therapy | Corticosteroids should be given concomitantly with antiparasitic agentse. | Given the data on worsening symptoms with antiparasitic drugs, most authorities recommend use of corticosteroids in patients treated with antiparasitic drugsf. | Strong; moderate | |
| Antiepileptic therapy | Antiepileptic drugs should be used in all patients with seizuresg. | Antiepileptic drugs can be discontinued after resolution of cystic lesions if no risk factors for recurrenceg. Risk factors for recurrent seizures include (1) calcifications on follow-up CT, (2) breakthrough seizures, and (3) >2 seizures during the course of the disease. | Strong; moderate | |
| Calcified parenchymal neurocysticercosis with or without perilesional edema | Antiparasitic therapy | Antiparasitic treatment not recommended. | There are no viable cysts and thus no indication for antiparasitic therapy. | |
| Antiepileptic therapy | Treatment with antiepileptic drugsg. | Management guidelines are similar to that in other patients with seizures. | Strong; moderate | |
| Anti-inflammatory therapy | Corticosteroids should not be routinely used.h | There are a few case reports suggesting that when corticosteroids are stopped or lowered previously quiescent calcifications develop perilesional edema. | Strong; low | |
| Cysticercal encephalitis (with diffuse cerebral edema) | Avoid antiparasitic drugs, treat diffuse cerebral edema with corticosteroidsi. | Cerebral edema mediated by the host inflammatory response. Antiparasitic drugs are associated with worsening edema. | Strong; low |
Abbreviations: CT, computed tomography; NCC, neurocysticercosis.
aTwo well-designed randomized trials demonstrated more rapid radiologic responses and fewer generalized seizures in patients treated with albendazole compared to placebo.
bThe combination of praziquantel and albendazole was superior to albendazole alone in patients with >2 cysts, but was not better in those with 1 or 2 viable cysts.
cThe optimal anti-inflammatory regimen has not been clearly defined. A trial comparing 6 mg/day of dexamethasone for 10 days with 8 mg/day for 28 days followed by a taper noted fewer seizures in the higher-dose group. Other studies have used prednisone 1–1.5 mg/kg/day during therapy.
dThere are no clear data on optimal duration of antiepileptic drugs. Risk factors for recurrent seizures include calcifications on follow-up CT, breakthrough seizures, and >2 seizures during the course of the disease. In patients without any of these risk factors and no seizures in the prior 3 months, antiepileptic drugs can be safely withdrawn within a few weeks of the resolution of the enhancing lesion on high-resolution imaging studies.
eTwo meta-analyses of randomized controlled trials have concluded that albendazole improved the outcome in patients with single enhancing lesions due to neurocysticercosis.
fAlbendazole should be given along with anti-inflammatory drugs. The optimal dose and duration has not been defined, but doses have included dexamethasone 0.1 mg/kg/day for the duration of therapy or 1–2 mg/kg/day of prednisone or prednisolone have been used.
gManagement guidelines are similar to those in other patients with seizures. Many can be managed with a single drug. There are no data on relative efficacy of different antiepileptic drugs.
hA few case reports suggest that when corticosteroids are lowered or stopped, rebound perilesional edema can occur. Therefore, anti-inflammatory drugs should be used cautiously, if at all, in patients presenting with perilesional edema around a calcified lesion.
iAntiparasitic agents can worsen cerebral edema and should generally be avoided in patients with increased intracranial pressure from either diffuse cerebral edema (cysticercal encephalitis) or untreated hydrocephalus.