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Neuro Cist Icer Coz A
Neuro Cist Icer Coz A
Neurocysticercosis
Address correspondence to
Dr Oscar H. Del Brutto, Air
Center 3542, PO Box 522970,
Miami, FL 33152-2970,
oscardelbrutto@hotmail.com. Oscar H. Del Brutto, MD, FAAN
Relationship Disclosure:
Dr Del Brutto has received
travel expenses for serving
on the Safe Implementation ABSTRACT
of Treatment of Stroke Purpose of Review: Neurocysticercosis occurs when humans become intermediate
steering committee.
Unlabeled Use of
hosts in the life cycle of Taenia solium by ingesting its eggs directly from a taenia
Products/Investigational carrier or, less often, by contaminated food. Within the nervous system, cysticerci may
Use Disclosure: Dr Del Brutto lodge in the brain parenchyma, subarachnoid space, ventricular system, or spinal cord,
reports no disclosure.
causing a number of pathologic changes that are responsible for the pleomorphism of
* 2012, American Academy
of Neurology. neurocysticercosis. This article discusses the clinical manifestations, diagnosis, and treat-
ment of neurocysticercosis.
Recent Findings: Formerly endemic in the developing world, mass immigration of
people from disease-endemic to nonendemic areas has caused a recent increase in the
prevalence of neurocysticercosis in developed countries, where this condition should no
longer be considered exotic. Recent advances in neuroimaging and immune diagnostic
methods, and the introduction of a set of diagnostic criteria, have enhanced the
diagnostic accuracy for neurocysticercosis. Likewise, introduction of potent cysticidal
drugs has radically changed its prognosis.
Summary: Neurocysticercosis is the most common helminthic infection of the CNS and
a major cause of acquired epilepsy worldwide. Diagnosis of neurocysticercosis is possible
after interpretation of clinical data together with findings of neuroimaging studies and
results of immunologic tests in a proper epidemiologic context. The use of cysticidal drugs
reduces the burden of infection in the brain and improves the clinical course of most
patients. Further efforts must be directed to eradicate the disease through the imple-
mentation of control programs against all interrelated steps in the life cycle of T. solium,
including human carriers of the adult tapeworm, infected pigs, and eggs in the environment.
KEY POINT
h The life cycle of Taenia
solium involves two
hosts: humans and pigs.
Humans are the only
definitive hosts for the
adult cestode, whereas
both pigs and humans
may act as intermediate
hosts for the larval form
called cysticercus.
FIGURE 8-2 World map showing major outbreaks of human cysticercosis related to mass
movement of people or infected swine from endemic to nonendemic areas. (1)
Return of British soldiers from India to England; (2) gift of infected swine from
Bali to Irian Jaya; (3) mass return of Portuguese living in African colonies after wars in Angola
and Mozambique; (4) migratory movements of people from Mexico and South America to the
United States (mainly to the southwestern and the New York City areas); (5) mass migration of
people from Ecuador, Perú, and Bolivia to Spain; (6) migration of people from India to countries
of the Arabian Peninsula (mainly Kuwait, Saudi Arabia, and Qatar).
FIGURE 8-3 Diagram of major steps in the life cycle of Taenia solium.
KEY POINT
h Defining a typical with the subsequent development of a CLINICAL MANIFESTATIONS
syndrome of cerebral infarction.10 Neurocysticercosis may produce no
neurocysticercosis is Ventricular cysticerci may also elicit clinical manifestations at all or may be
unrealistic. In endemic an inflammatory reaction if they are severe enough to cause the death of the
areas this parasitic attached to the choroid plexus or to the patient. This pleomorphism is related
disease has traditionally ventricular wall. The ependymal lining to individual differences in the num-
been considered the is disrupted, and proliferating subepen- ber and location of the lesions as well
‘‘great imitator,’’ as it dymal glial cells protrude toward the as in the severity of the host’s immune
may mimic almost any ventricular cavities, blocking the transit response to the parasite. Therefore, defin-
neurologic disorder. of CSF, particularly when the site of ing a typical syndrome of neurocysticer-
protrusion is at or near the foramina of cosis is unrealistic. In endemic areas this
Monro or the cerebral aqueduct.9 parasitic disease has traditionally been con-
sidered the ‘‘great imitator,’’ as it may
Immune Response mimic almost any neurologic disorder.12
Against Cysticerci A recent systematic review showed that
Some cysticercal antigens play a role in recurrent seizures occur in approximately
the evasion of the immune surveillance 80% of symptomatic neurocysticercosis
against the parasite. One of them, an- cases, confirming previous findings that
tigen B, is a paramyosin with affinity for epilepsy is the most common clinical man-
collagen that may bind to C1q, inhibit- ifestation of the disease.13 Other man-
ing the classic pathway of complement ifestations of neurocysticercosis include
activation. Since destruction of cysticerci focal neurologic deficits (16%), increased
seems to be mediated by activation of intracranial pressure (12%), and cognitive
the complement cascade, antigen B decline (5%). Cysticercosis outside the
could play a role in the protection of CNS is not associated with clinical man-
cysticerci against the host’s immuno- ifestations, with the exception of ocular
logic attack. Host immunoglobulins have cysticercosis and some cases with mas-
been found around living intracranial sive muscular involvement.12
cysts, suggesting that cysticerci use these Cysticercosis affects males and females
molecules as a screen to avoid recogni- equally from infancy to old age, with a
tion from the immune system. peak incidence among middle-aged
Some reports suggest the occur- adults. The course of the disease is some-
rence of cellular immune dysfunction what different in infants and children
in patients with neurocysticercosis. This compared to adults, and neurocysticerco-
impairment results from an increase in sis tends to be more severe in women.
the subpopulations of CD8 T lympho- The reasons for these findings are incom-
cytes, impaired proliferation of lympho- pletely understood; however, it is possi-
cytes, and abnormal concentration of ble that the interaction of several factors,
cytokines. The depressed cellular immu- including increased reactivity of the
nity may be responsible for the associa- immune system in children and women,
tion of neurocysticercosis with conditions could be responsible for the age- and
resulting from immunodeficiency states gender-related observed differences in
and glial tumors. In the latter, the in- the pattern of disease expression.
tense glial proliferation around the para- Geographic differences in the clinical
sites, along with the suppression of the spectrum of the disease have also been
cellular immune responses, may cause noted. For unclear reasons, subcutaneous
inhibition of the immunologic surveil- and muscular cysticercosis is observed
lance against cancer, leading to malig- far more frequently in Asia and Africa
nant transformation of astrocytes.11 than in the Americas. Moreover, almost
KEY POINT
h The frequency of disturbances below the level of the testing to severe dementia, may occur
positive stool lesion that may be associated with in some patients with neurocysticercosis,
examinations for radicular pain when cysts are located particularly in those with chronic normal
T. solium eggs has in the spinal subarachnoid space.23 pressure hydrocephalus.12 Before the
varied from one series introduction of CT, these patients were
to another and seems Intracranial Hypertension admitted to psychiatric hospitals for
to be related to the Various mechanisms explain the occur- years until the correct diagnosis was
severity of infection. rence of increased intracranial pressure suspected because of the occurrence
Patients with heavy in patients with neurocysticercosis. of seizures or focal neurologic signs.
infections have a Some patients with parenchymal brain
The most common is hydrocephalus,
greater chance of also
which, in turn, is most often related to lesions develop psychotic episodes char-
having taeniasis.
inflammatory occlusion of the Luschka acterized by confusion, paranoid idea-
and Magendie foramina, although some tion, psychomotor agitation, violent
patients develop hydrocephalus be- behavior, and visual hallucinations;
cause of blockage of CSF circulation by some of these episodes could repre-
ventricular cysts or ependymitis occlud- sent attacks of psychomotor epilepsy
ing Monro foramina or the cerebral or postictal psychosis.
aqueduct.24 The clinical course of in-
creased intracranial hypertension in DIAGNOSIS
patients with hydrocephalus due to Peripheral eosinophilia is a common,
basal arachnoiditis is subacute or albeit nonspecific, hematologic abnor-
chronic, while that of patients with mality in patients with neurocysticerco-
hydrocephalus related to fourth ven- sis. The frequency of positive stool
tricle cysts may be punctuated by examinations for T. solium eggs among
episodes of sudden loss of conscious- these patients has varied from one
ness related to movements of the head series to another and seems to be re-
(Bruns syndrome), and that of cerebral lated to the severity of infection. Pa-
aqueduct stenosis may be associated tients with heavy infections have a
with paroxysmal headache and Pari- greater chance of also having taenia-
naud syndrome (Case 8-1). sis.25,26 Recognition of Taenia eggs is
Irrespective of their pathogenetic not easy, and many patients may es-
mechanism, hydrocephalus is an omi- cape detection when coproparasitologic
nous sign associated with high mortality studies are performed. Specific coproan-
rates. tigen detection by ELISA and PCR has
Intracranial hypertension may also improved the screening for T. solium
be related to the occurrence of the so- carriers.27
called cysticercotic encephalitis, which Nonspecific abnormalities in the
is a severe form of parenchymal neuro- cytochemical composition of CSF are
cysticercosis that usually affects children common in patients with neurocysti-
and young women (Case 8-2). Patients cercosis. These abnormalities directly
with cysticercotic encephalitis present correlate with the activity of the disease
with cloudiness of consciousness of acute and with whether or not the parasites
or subacute onset associated with sei- are located in the subarachnoid space.
zures, decreased visual acuity, headache, The most common finding is a moder-
vomiting, and papilledema.12 ate mononuclear pleocytosis, with cell
counts rarely exceeding 300/2L. Mild
Cognitive Decline increase in CSF protein counts, usually
Cognitive decline, ranging from poor in the range of 50 mg/dL to 300 mg/dL,
performance on neuropsychological is also common. CSF glucose levels are
1400 www.aan.com/continuum December 2012
Case 8-2
A 20-year-old woman presented with a 1-week history of progressive headache, vomiting, and
somnolence. On admission, neurologic examination showed obtundation, bilateral papilledema
(Figure 8-8), increased muscle stretch reflexes, and bilateral Babinski signs. MRI showed diffuse brain
swelling with collapse of the ventricular system, and multiple small cysticerci disseminated through the
brain parenchyma with predominance of the cerebral cortex.
Lesions showed a ringlike pattern of enhancement after
contrast medium administration (Figure 8-9). Serum
immunoblot for the detection of anticysticercal antibodies was
strongly positive. ELISA and Western blot for the detection
of antibodies against HIV were negative. High doses of
dexamethasone (8 mg IV every 8 hours) and mannitol
(100 mL of a 20% solution every 6 hours) were started.
Standard doses of sodium phenytoin were also added to
the regimen. The patient improved over the next few days.
Mannitol was discontinued after 3 days, and IV
dexamethasone was switched to oral prednisone after 1 week.
She was discharged asymptomatic 2 weeks after admission.
Comment. This young woman had cysticercotic encephalitis,
FIGURE 8-8 Funduscopic examination a severe form of neurocysticercosis related to an intense
showing papilledema. inflammatory reaction from the host in response to massive
cysticerci infestation of the brain parenchyma. Diagnosis is
suspected on clinical and imaging grounds and must be confirmed by the practice of a serum immunoblot
test. It is also prudent to evaluate the HIV status of the patient, since Toxoplasma encephalitis or other
HIV-related opportunistic infections of the nervous system may occur with similar clinical and
neuroimaging
findings. Cysticidal
drugs are formally
contraindicated
in patients with
cysticercotic
encephalitis, as
therapy may
exacerbate the
inflammatory
reaction within the
brain parenchyma,
causing further FIGURE 8-9 MRI of patient with cysticercotic encephalitis. A, T1-weighted imaging showing
diffuse brain edema with collapse of the ventricular system. B, T2-weighted
increase in the imaging showing multiple colloidal parenchymal brain cysts surrounded by edema. C, After contrast
intracranial pressure administration, cysticerci appear as ring-enhancing lesions.
and death. In
contrast, prompt administration of corticosteroid and osmotic diuretics usually result in marked clinical
improvement. Decompressive craniotomies have been suggested for patients who do not respond to this
initial therapeutic approach. Patients who survive recover without sequelae, and further neuroimaging
studies from 3 to 6 months after the acute episode usually show complete resolution of lesions.
KEY POINTS
h CT remains the best
screening neuroimaging
procedure for patients
with suspected
neurocysticercosis,
since many patients
have parenchymal
brain calcifications as
the sole evidence of
the disease, and many
of these lesions may
escape detection if only Imaging findings in parenchymal brain cysticercosis. A, T1-weighted MRI of
FIGURE 8-10
an MRI is performed. vesicular cysticerci showing scolices. B, Contrast-enhanced MRI showing single
colloidal cysticercus. C, Plain CT showing parenchymal brain calcifications.
h Many vesicular cysts
have in their interior an
eccentric hyperdense
severity of the host’s inflammatory (Figure 8-10). Vesicular cysticerci ap-
nodule representing the
reaction against the parasites. While pear as small and rounded cystic lesions
scolex, giving the lesions
a pathognomonic
MRI is the preferred method for evalu- that are well demarcated from the sur-
‘‘hole-with-dot’’ ating patients with cystic lesions located rounding brain parenchyma. Imaging
appearance. in the ventricular system, the brain- shows little or no perilesional edema
stem, and the subarachnoid space, CT and no abnormal enhancement after
remains the best screening neuroimag- contrast-medium administration. Many
ing procedure for patients with sus- vesicular cysts have in their interior
pected neurocysticercosis, since many an eccentric hyperdense nodule repre-
patients have parenchymal brain calcifi- senting the scolex, giving the lesions
cations as the sole evidence of the a pathognomonic ‘‘hole-with-dot’’
disease, and many of these lesions appearance. When the infection is
may escape detection if only an MRI is massive, as in the so-called heavy non-
performed.30 encephalitic form of neurocysticerco-
Parenchymal neurocysticercosis. sis,25 the brain looks like a ‘‘Swiss
The stage of involution of parenchy- cheese,’’ another imaging finding that
mal brain cysticerci determines their is pathognomonic of neurocysticercosis
appearance on neuroimaging studies (Figure 8-11).
KEY POINTS
h Cystic lesions located
within the sylvian
fissures or at the CSF
cisterns at the base of
the brain usually attain
a large size and have
a multilobulated
appearance (the
racemose form of
neurocysticercosis),
displacing neighboring
structures and behaving FIGURE 8-13 Imaging findings in subarachnoid cysticercosis. A, Contrast-enhanced CT
as space-occupying showing large cyst in sylvian fissure. B, Contrast-enhanced CT showing
hydrocephalus associated with cysts in CSF cisterns. C, T1-weighted MRI showing huge cyst
mass lesions. compressing brainstem.
h Cyst mobility within
the ventricular cavities
in response to
movements of the
neurocysticercosis), displacing neigh- related infarcts, the association of sub-
head, the ventricular boring structures and behaving as space- arachnoid cystic lesions (particularly at
migration sign, occupying mass lesions (Figure 8-13). the suprasellar cistern) or abnormal en-
facilitates the diagnosis Another common finding in patients hancement of basal leptomeninges sug-
of ventricular with subarachnoid neurocysticercosis is gests the correct diagnosis.10 Angiographic
cysticercosis in hydrocephalus caused by inflammatory findings in subarachnoid neurocysticerco-
some cases. occlusion of the Luschka and Magen- sis include segmental narrowing or oc-
die foramina. The fibrous arachnoidi- clusion of the major intracranial arteries
tis responsible for the development of in patients with infarcts (Figure 8-14)
hydrocephalus is seen on CT or MRI as or even in those lacking clinical or neu-
areas of abnormal leptomeningeal en- roimaging evidence of a cerebral infarct.
hancement at the base of the brain.24,30 Magnetic resonance angiography is a
Cerebrovascular complications of neu- valuable noninvasive imaging modality
rocysticercosis are well visualized with to demonstrate narrowing or occlusion
CT or MRI. In patients with cysticercosis- of intracranial arteries in patients with
subarachnoid neurocysticercosis.
Ventricular neurocysticercosis. Ven-
tricular cysticerci appear on CT as
hypodense lesions that distort the ven-
tricular system, causing asymmetric ob-
structive hydrocephalus. Ventricular
cysts are isodense with CSF; there-
fore, they cannot be directly visual-
ized (Figure 8-15). In contrast, most
ventricular cysts are readily visualized
on MRI because the signal properties
of the cystic fluid or the scolex dif-
fer from those of the CSF.30 Cyst mo-
Cysticercotic angiitis. A, Plain CT showing bility within the ventricular cavities in
FIGURE 8-14
infarct in territory of left anterior cerebral response to movements of the head,
artery. B, Angiogram showing segmental
narrowing of A1 segment of left anterior the ventricular migration sign, facili-
cerebral artery. tates the diagnosis of ventricular cysti-
cercosis in some cases. In other patients,
Unification of
Diagnostic Criteria
Despite the introduction of the above-
FIGURE 8-15 Plain CT showing described immune diagnostic tests and
ventricular
cysticercus causing asymmetric
neuroimaging methods, the diagnosis of
dilatation of right lateral ventricle. neurocysticercosis can still be a challenge
because clinical manifestations are non-
specific, neuroimaging findings are often
not pathognomonic, and immune diag-
parasitic membranes or ventriculitis nostic tests are faced with problems
occlude the Monro foramina. In such related to poor sensitivity or specificity.
cases, it is common to observe Moreover, histologic demonstration of
asymmetric internal hydrocephalus, the parasite is not possible in most cases.
most often noticed after the placement During the second half of the 20th
of a ventricular shunt, as the lateral century, it was common in field studies
ventricle contralateral to the shunt to diagnose neurocysticercosis in pa-
remains dilated after the derivative tients presenting with seizures and
procedure. A particular finding in ven- a positive immunologic test for the
tricular cysticercosis is the so-called detection of anticysticercal antibodies
double compartment hydrocephalus,
in which the fourth ventricle is isolated
from the rest of ventricular cavities
because of simultaneous occlusion of
the cerebral aqueduct and the foramina
of Luschka and Magendie (Case 8-1).
Spinal cord neurocysticercosis.
While myelography and CT were used
for years for the diagnosis of spinal
cysticercosis, they are now of historical
significance since MRI has become the
imaging modality of choice for the
evaluation of patients with suspected
cysticercosis of the spinal cord or the
spinal subarachnoid space. On MRI, T1-weighted gadolinium
FIGURE 8-16
intramedullary cysticerci appear as contrast-enhanced MRI
of patient with spinal
rounded or septated lesions that may cysticercosis showing multiple hypointense
have an eccentric hyperintense nodule cystic lesions in the spinal canal.
representing the scolex.30 If the scolex
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Copyright @ American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Neurocysticercosis
KEY POINTS
h Revised criteria for in serum. Such practice could have were frequent but nonspecific manifes-
the diagnosis of resulted in the inclusion of many pa- tations of the disease; and epidemio-
neurocysticercosis include tients who actually had cryptogenic logic criteria referred to circumstantial
four categoriesVabsolute, epilepsy and false-positive results on evidence favoring the diagnosis. Inter-
major, minor, and immunologic testing. On the other pretation of these criteria permitted
epidemiologicVstratified hand, some infected persons escaped two degrees of diagnostic certainty: (1)
on the basis of their detection just because they had neg- definitive diagnosis in patients who
individual diagnostic ative immunologic study results. In the had one absolute criterion or in those
strength. Absolute criteria hospital setting, diagnosis of neurocys- who had two major plus one minor
allow unequivocal ticercosis usually rested only on neuro- and one epidemiologic criteria; and (2)
diagnosis; major criteria
imaging findings. Using this approach, probable diagnosis in patients who
strongly suggest the
neurocysticercosis could be overdiag- had one major plus two minor criteria,
diagnosis but cannot be
used alone to confirm the
nosed in endemic areas. In contrast, this in those who had one major plus one
diagnosis; minor criteria disease used to be overlooked in other minor and one epidemiologic criteria,
are frequent but regions of the world simply because it and in those who had three minor plus
nonspecific manifestations was rare. Such diagnostic pitfalls could one epidemiologic criteria (Table 8-2).34
of the disease; and lead either to the progression of other This set of diagnostic criteria was
epidemiologic criteria diseases requiring urgent therapy or to promptly adopted by the medical com-
refer to circumstantial the practice of unnecessary and inva- munity and is now considered by many
evidence favoring the sive diagnostic procedures. as the gold standard for the diagnosis
diagnosis. In 1996, the first attempt to settle a of neurocysticercosis.
h Accurate characterization chart of diagnostic criteria for human Advances in neuroimaging from the
of neurocysticercosis in cysticercosis was published, based on time of that publication should be incor-
terms of viability of cysts, the objective evaluation of clinical, porated in the subheading of ‘‘highly
degree of the host’s radiologic, immunologic, and epide- suggestive lesions’’ to enhance the di-
immune response to the miologic data of patients.33 After some agnostic accuracy of MRI. These include
parasites, and location
years of experience, the same group of the use of diffusion-weighted imaging
of the lesions is important
investigators considered that chart to to visualize the scolex in doubtful cases,
for a rational therapy.
be somewhat confusing and complex, the use of susceptibility-weighted images
since it was developed for the diag- to enhance the identification of calcifica-
nosis of patients with neurocysticerco- tions, and the practice of spectroscopy to
sis as well as those with systemic differentiate neurocysticercosis from
cysticercosis. With few exceptions, cys- neurotuberculosis in selected cases.30Y32
ticercosis outside the CNS is not clinically
relevant. Therefore, it was considered THERAPY
that a more accurate and stringent set of Accurate characterization of neurocysti-
diagnostic criteria exclusively devoted to cercosis in terms of viability of cysts,
the diagnosis of neurocysticercosis would degree of the host’s immune response
be more comprehensible than those to the parasites, and location of the
initially identified.34 As in the 1996 lesions is important for a rational ther-
publication, revised criteria included four apy.35 Therapeutic approaches may
categoriesVabsolute, major, minor, and include a combination of symptomatic
epidemiologicVstratified on the basis therapy, cysticidal drugs, surgical resec-
of their individual diagnostic strength. tion of lesions, and placement of ven-
Absolute criteria allowed unequivocal tricular shunts. General strategies of
diagnosis of neurocysticercosis; major therapy described in Table 8-3 may
criteria strongly suggested the diagno- need some adjustment in the individual
sis but could not be used alone to patient, particularly in those who have
confirm the diagnosis; minor criteria mixed forms of the disease.
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b Diagnostic Criteria
Presence of one major plus one minor and one epidemiologic criteria
Presence of three minor plus one epidemiologic criteria
a
Reprinted from Del Brutto OH, et al, Neurology.34 B 2001, with permission from American Academy of
Neurology. www.ncbi.nlm.nih.gov/pmc/articles/PMC2912527/.
b Parenchymal Neurocysticercosis
Cysticercotic encephalitis: Cysticidal drugs are contraindicated. Use corticosteroids and osmotic diuretics to
reduce brain swelling. Use AEDs for seizures. Perform decompressive craniotomies in refractory cases.
Cysticercosis of the spine: Perform surgical resection of lesions. Anecdotal use of albendazole with
good results has been reported.
a
Level 1 evidence favors the use of cysticidal drugs in patients with parenchymal brain vesicular and colloidal cysts. For other forms
of the disease, guidelines are based on Level 2 and Level 3 evidence.
KEY POINTS
h The use of albendazole must be treated with AEDs regardless niotomies to avoid the life-threatening
results not only in a of the specific cysticidal drug used. The risk of intracranial hypertension.
more expedited length of AED therapy will depend on
resolution of colloidal whether the lesions disappear or are Extraparenchymal
cysticerci, but also in a transformed into calcifications as the Neurocysticercosis
reduction of the risk of result of therapy.36 Subarachnoid cysts. Medical treatment
seizure recurrence in Dying parenchymal brain (colloidal) of small subarachnoid cysts over the
most patients. cysts. Colloidal cysts are degenerating convexity of cerebral hemispheres is
h Cysticidal drugs must parasites that result from the host’s im- similar to that described for parenchy-
not be used in patients munologic attack, so the natural history mal brain cysts; the only difference is
with cysticercotic of most of these lesions would be to that albendazole is the preferred drug
encephalitis, since these vanish or end up as a calcified nod- because it penetrates the subarachnoid
drugs may exacerbate ule.29 While some of these lesions may space better and reaches higher con-
the inflammatory disappear without therapy, Level 1 evi- centrations in the CSF than praziquan-
response within the
dence also favors the use of cysticidal tel. Clinical experience with this form
brain parenchyma that
drugs in these patients.38 According to of the disease is limited, but Level 2 evi-
occurs in this severe
form of parenchymal
a number of double-blind trials, the use dence suggests that the percentage of
neurocysticercosis. of albendazole results not only in a small subarachnoid cysts disappearing
more expedited resolution of colloi- after albendazole treatment is similar
h Higher doses of
dal cysticerci, but also in a reduction to that reported for parenchymal cysts.43
albendazole, more
prolonged courses of
of the risk of seizure recurrence in Treatment of giant cysts located in-
therapy, or even repeated most patients.40Y42 As described for pa- side CSF cisterns is controversial (Level 3
cycles may be needed tients with vesicular cysts, many patients evidence). While some authors recom-
for patients with with colloidal cysts also experience ad- mend surgical resection of these le-
racemose cysticercus. verse reactions during the trial of cystici- sions, it has been suggested that medical
h Routine corticosteroid dal drugs. In such cases, simultaneous therapy with albendazole may be an
administration is administration of corticosteroids usu- equally effective albeit less aggressive
mandatory when ally results in prompt relief of symp- approach. Higher doses of albenda-
treating patients with toms. The length of AED therapy will zole, more prolonged courses of ther-
large subarachnoid cysts also be related to whether colloidal cysts apy, or even repeated cycles may be
with albendazole, in vanished or were transformed into calci- needed for patients with racemose
order to avoid the fied nodules as the result of therapy, as it cysticercus (Table 8-3).24,44,45 In addi-
hazard of a cerebral is generally accepted that in the latter tion to the dramatic improvement in-
infarct. case, the risk of seizure recurrences duced by albendazole on neuroimaging
after AED withdrawal is high.29 studies, reports have shown marked
Cysticidal drugs must not be used in improvement in the neurologic mani-
patients with cysticercotic encephalitis, festations, mainly in focal neurologic
since these drugs may exacerbate the deficits, after therapy. Because of the
inflammatory response within the brain vicinity of blood vessels arising from
parenchyma that occurs in this severe the circle of Willis, it is possible that the
form of parenchymal neurocysticerco- inflammatory reaction that follows
sis. High doses of corticosteroids and destruction of the cysts enhances a
osmotic diuretics are advised as the first process of endarteritis resulting in a
therapeutic measures in order to reduce cerebral infarct. Routine corticosteroid
the severity of brain edema (Case 8-2). administration is mandatory when
This therapeutic approach should be treating patients with large subarach-
prolonged for 2 to 3 weeks until the noid cysts with albendazole to avoid
edema subsides. Refractory cases the hazard of a cerebral infarct. Corti-
should undergo decompressive cra- costeroids must be given before the
1412 www.aan.com/continuum December 2012
TABLE 8-4 Strategies for Elimination of Taeniasis and Cysticercosis h Patients with
hydrocephalus due to
b Community Level cysticercotic arachnoiditis
usually have a protracted
Improving living conditions course and a poor
Health education and awareness of mechanisms of disease acquisition prognosis. The main
problem in these cases
Mass human chemotherapy (useless without education) is the high frequency of
b Infected Pigs shunt dysfunction.
Mortality, which can
Improved husbandry (pig corralling) be as high as 50% at
Slaughterhouse control 2 years, has been directly
related to the number
Control of illegal markets for infected pigs of surgical interventions
Freezing of pork meat before human consumption to change the shunt.
h The surgeon must
Mass chemotherapy of pigs
always consider the
Pig vaccination possibility of cyst
migration within the
ventricular cavities from
the time of diagnosis
start of albendazole therapy, and their drugs. While some reports suggest that to the moment of
use must be prolonged for several days albendazole therapy destroys ventricu- surgery.
after the trial has been completed.24,44,45 lar cysts, consensus guidelines, based on
Hydrocephalus. Patients with hydro- Level 3 evidence, have favored surgical
cephalus due to cysticercotic arachnoidi- resection of most of these lesions, with
tis require a ventricular shunt before other the possible exception of small cysts lo-
therapeutic measures are attempted.35 cated in the lateral ventricle (a site where
In contrast, not all patients with hydro- the inflammatory reaction secondary to
cephalus due to ventricular cysts need destruction of the cyst is not danger-
a derivative procedure. In the latter, the ous).35 Surgical approaches include direct
need for a ventricular shunt depends excision of the cyst or endoscopic aspira-
on the location of the cyst and the co- tion using a flexible ventriculoscope.
existence of granular ependymitis. The surgeon must always consider the
Patients with hydrocephalus due to cys- possibility of cyst migration within the
ticercotic arachnoiditis usually have a ventricular cavities from the time of di-
protracted course and a poor progno- agnosis to the moment of surgery; there-
sis. The main problem in these cases is fore, it must be a routine practice to
the high frequency of shunt dysfunc- obtain a control neuroimaging study im-
tion. Mortality, which can be as high as mediately before surgery to avoid an un-
50% at 2 years, has been directly re- necessary surgical procedure.
lated to the number of surgical interven- In patients without associated epen-
tions to change the shunt.24 Continuous dymitis, permanent shunting procedures
administration of prednisone may re- are unnecessary after the excision of a
duce the risk of shunt dysfunction (Level ventricular cyst. In contrast, placement
3 evidence). of a ventricular shunt must follow or
Ventricular cysts and ependymitis. even precede excision of the cyst in
Depending on its size and location, patients who also have granular epen-
ventricular cysticercosis may be treated dymitis. Surgical excision of a ventricular
by surgical resection or by cysticidal cysticercus associated with ependymitis
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Copyright @ American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Neurocysticercosis
KEY POINT
h Neurocysticercosis is more difficult than excision of a freely end of the 19th century. To be effective,
eradication programs floating cyst, and it has been suggested however, eradication programs must be
must be directed to all that the efforts of therapy must be directed to all the targets for control,
the targets for control, primarily directed to the resolution of particularly human carriers of the adult
particularly human hydrocephalus by a ventricular shunt tapeworm, infected pigs, and eggs in the
carriers of the adult and not to cyst removal. A peculiar form environment (Table 8-4). Since these
tapeworm, infected of ventricular neurocysticercosis is dou- targets represent interrelated steps in
pigs, and eggs in the ble compartment hydrocephalus, caused the life cycle of T. solium, inadequate
environment. by the dual effect of granular ependymitis coverage of one of them may result in a
of the cerebral aqueduct and arachnoidi- rebound in the prevalence of taeniasis/
tis occluding the foramina of Luschka cysticercosis after the program has been
and Magendie. In these patients, two completed.5,46,47
independent shunt devices may be
needed, with one draining the supra-
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