Table 3.
Recommendations for Therapy of Extraparenchymal Neurocysticercosis
| Form | Recommended Therapy | Comment | Strength of Recommendation; Quality of Evidence |
|---|---|---|---|
| Intraventricular (lateral or third ventricle) |
Removal of the cysticerci by minimally invasive, neuroendoscopy when feasiblea,b. | Most cases with isolated nonadherent cysts in the lateral or third ventricle can be cured by neuroendoscopy and do not require subsequent antiparasitic drugs or shunt therapy if all cysticerci are removed. | Strong; low |
| Intraventricular (fourth ventricle) |
Either endoscopic or microsurgical cystectomy is suitable, depending on the experience of the surgeon. | Microsurgical resection is from a suboccipital approach. The endoscopic approach can be either from the conventional lateral-third ventricular-trans aqueductal route (technically demanding) or through the posterior approach. | Strong; low |
| Intraventricular—when surgical removal not feasible (eg, adherent cyst) | CSF diversion via a ventriculoperitoneal shuntc. | In cases of marked inflammation in the ventricles or degenerating cysticerci, the cyst may adhere to the ventricular wall, making removal hazardous. CSF diversion with medical therapy is the recommended approachc. | Weak; low |
| Adjuvant antiparasitic and anti-inflammatory therapyc. | Medical therapy should be limited to patients in whom surgery is contraindicated due to various reasons. A CSF diversion (shunt) should always be performed prior to chemotherapy if there is hydrocephalus, since there are reports of precipitation of hydrocephalus with antiparasitic therapy. | Strong; moderate | |
| Subarachnoidd | Surgical management of hydrocephalus | Initial management should focus on treatment of hydrocephalus. This often requires ventriculoperitoneal shunting. | Strong; low |
| Antiparasitic therapye | Subarachnoid cysts do not respond well to typical doses and durations of therapy. Options to improve responses include prolonged administration of albendazole (15 mg/kg/d for months) or combination therapy with albendazole (15 mg/kg/d plus praziquantel 50 mg/ kg/d). | Strong; low | |
| Anti-inflammatory therapy | Concomitant administration of corticosteroids with antiparasitic drugs is essential in the treatment of patients with subarachnoid neurocysticercosis. Inflammation is exacerbated as a result of antiparasitic treatmentf. | Strong; low |
Abbreviation: CSF, cerebrospinal fluid.
aThe endoscopic surgical approach often requires ventriculomegaly. Cyst rupture is the norm and not associated with adverse consequences. The microsurgical approach is also facilitated by presence of hydrocephalus.
bAlternative approaches include CSF diversion along with medical management, or craniotomy with microsurgical excision.
cShunts are initially efficacious acutely for hydrocephalus, but there is a very high rate of shunt malfunction in patients with neurocysticercosis. Shunt failure may be lower when combined with corticosteroids and antiparasitic treatment.
dSubarachnoid neurocysticercosis should be aggressively treated with antiparasitic and anti-inflammatory drugs. Hydrocephalus should be addressed before antiparasitic therapy.
eUntreated hydrocephalus is a contraindication to antiparasitic therapy and needs to be treated first. Some cases respond to anti-inflammatory treatment, but most cases require CSF diversion.
fGenerally, 1 mg/kg/day of prednisone or .2–.4 mg/kg/day of dexamethasone are administered 3–4 days before and during antiparasitic treatment. The dose is slowly decreased, depending on the intensity of the inflammatory response. Methotrexate or antibody to tumor necrosis factor can be used as steroid-sparing agents.