AAN Issues Guideline on Parenchymal Neurocysticercosis

Megan Brooks

April 09, 2013

A combination of albendazole plus a corticosteroid should be considered for adults and children with parenchymal neurocysticercosis, a new evidence-based guideline from the American Academy of Neurology (AAN) advises.

Neurocysticercosis is an infection of the brain or spinal cord caused by the tapeworm Taenia solium. It causes seizures, swelling of the brain, and other symptoms. Neurocysticercosis can be acquired via fecal-oral transmission from a carrier of the adult tapeworm or by accidental ingestion of food contaminated with T solium eggs.

"The World Health Organization [WHO] considers neurocysticercosis the most common preventable cause of epilepsy in the world," Joseph R. Zunt, MD, who worked on the guidelines, told Medscape Medical News. The WHO estimates that roughly 2 million people worldwide have epilepsy caused by T solium infection.

"Over the past decade, growing interest in global health, as well as increasing numbers of patients with neurocysticercosis presenting for evaluation and treatment in the United States, have led to increased awareness of this infection," added Dr. Zunt, professor in the departments of neurology and global health and adjunct professor, departments of medicine (infectious diseases) and epidemiology, at the University of Washington, Seattle.

The new AAN guideline is published April 9 in Neurology. The guideline has also been endorsed by the American Epilepsy Society.

The new document focuses solely on the efficacy of treatment for parenchymal neurocysticercosis, the most common manifestation of neurocysticercosis, he explained. The recommendations are based on a review of 10 class I or II trials of cysticidal drugs administered with or without corticosteroids.

On the basis of the evidence reviewed, the guideline recommends that albendazole (400 mg twice daily for adults or weight-based dosing for either adults or children) plus either dexamethasone or prednisolone should be considered for adults and children with neurocysticercosis, both to decrease the number of active lesions on brain imaging studies (level B) and to reduce the long-term seizure frequency (level B).

In most studies, corticosteroids were coadministered, in varying dosages, and this combination "appears effective," the guideline says. However, evidence is insufficient to support or refute the use of corticosteroids alone, and no studies are available help determine when during the course of antiparasitic treatment steroids should be started.

The efficacy of antiepileptic drug therapy in treating or decreasing the occurrence of subsequent seizures secondary to parenchymal neurocysticercosis is also unclear.

"Thoughtful" Review

A. Clinton White, MD, from the University of Texas Medical Branch at Galveston, who was not involved in the guideline, said the authors have provided a "very careful review of the literature but only for a small part of the spectrum of cysticercosis. They've limited it to [studies] that are published and limited it to parenchymal cysticercosis."

"Within those limitations," Dr. White said, the authors have provided "some insights into the strengths and weaknesses of different approaches. I think what they've presented is well done and their recommendations are very thoughtful."

But he also told Medscape Medical News that there are "some new data that have not yet been published that will suggest an approach significantly different than what was outlined in the guideline."

Dr. White also noted that there has been "a lot of controversy in the management of neurocysticercosis. The disease is very complex and there are many different forms of infection, all of which vary considerably in how they present, what causes them, and how they should be managed. It's very important for guidelines to distinguish different forms of cysticercosis."

Dr. White is chairman of an Infectious Diseases Society of America committee that is developing a guideline on the diagnosis and management of cysticercosis, which is expected to be published sometime next year.

The guideline was developed with support from the AAN. None of the authors received reimbursement, honoraria, or stipends for their participation in its development.

Neurology. 2013;80:1424-1429. Abstract