Albendazole in single CT ring lesions in epilepsy

Anthelmintics for people with neurocysticercosis

BACKGROUND

Neurocysticercosis is a parasitic infection of the central nervous system by the larval stage of the pork tapeworm and is a common cause of seizures and epilepsy in endemic areas. Anthelmintics (albendazole or praziquantel) may be given alongside supportive treatment (antiepileptics/analgesia) with the aim of killing these larvae (cysticerci), with or without corticosteroid treatment. However, there are potential adverse effects of these drugs, and the cysticerci may eventually die without directed anthelminthic treatment.

OBJECTIVES

To assess the effects of anthelmintics on people with neurocysticercosis.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, the WHO ICTRP, and ClinicalTrials.gov, up to 21 October 2020.

SELECTION CRITERIA

Randomized controlled trials comparing anthelmintics and supportive treatment (+/- corticosteroids) with supportive treatment alone (+/- corticosteroids) for people with neurocysticercosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the title and abstract of all articles identified by the search. We obtained full-text articles to confirm the eligibility of all studies that passed screening. One review author extracted data, which a second review author checked. Two review authors assessed the risk of bias of each trial and performed GRADE assessments. In cases of disagreement at consensus discussion stage between review authors, we consulted a third review author. We calculated risk ratios (RR) for dichotomous variables, with 95% confidence intervals (CIs) for pooled data from studies with similar interventions and outcomes.

MAIN RESULTS

We included 16 studies in the review. Only two studies investigated praziquantel and did not report data in a format that could contribute to meta-analysis. Most results in this review are therefore applicable to albendazole versus placebo or no anthelmintic. The aggregate analysis across all participants with neurocysticercosis did not demonstrate a difference between groups in seizure recurrence, but heterogeneity was marked (RR 0.94, 95% CI 0.78 to 1.14; 10 trials, 1054 participants; I² = 67%; low-certainty evidence). When stratified by participants with a single cyst or multiple cysts, pooled analysis suggests that albendazole probably improves seizure recurrence for participants with a single cyst (RR 0.61, 95% CI 0.4 to 0.91; 5 trials, 396 participants; moderate-certainty evidence). All studies contributing to this analysis recruited participants with non-viable, intraparenchymal cysts only, and most participants were children. We are uncertain whether or not albendazole reduces seizure recurrence in participants with multiple cysts, as the certainty of the evidence is very low, although the direction of effect is towards albendazole causing harm (RR 2.05, 95% CI 1.28 to 3.31; 2 trials, 321 participants; very low-certainty evidence). This analysis included a large study containing a highly heterogeneous population that received an assessment of unclear risk for multiple 'Risk of bias' domains. Regarding radiological outcomes, albendazole probably slightly improves the complete radiological clearance of lesions (RR 1.22, 95% CI 1.07 to 1.39; 13 trials, 1324 participants; moderate-certainty evidence) and the evolution of cysts (RR 1.27, 95% CI 1.10 to 1.47; 6 trials, 434 participants; moderate-certainty evidence). More adverse events appeared to be observed in participants treated with either albendazole or praziquantel compared to those receiving placebo or no anthelmintic. The most commonly reported side effects were headache, abdominal pain, and nausea/vomiting.

AUTHORS' CONCLUSIONS

For participants with a single cyst, there was less seizure recurrence in the albendazole group compared to the placebo/no anthelmintic group. The studies contributing to this evidence only recruited participants with a non-viable intraparenchymal cyst. We are uncertain whether albendazole reduces seizure recurrence for participants with multiple cysts. We also found that albendazole probably increases radiological clearance and evolution of lesions. There were very few studies reporting praziquantel outcomes, and these findings apply to albendazole only.

Controversies in the treatment of seizures associated with neurocysticercosis

Seizures are the commonest manifestation of brain parenchymal cysticercosis. In terms of pathophysiological basis and prognostic significance of the seizures, a distinction might be applied between viable cysts, solitary cysticercus granuloma and calcific cysticerci. A number of uncertainties shroud the management of seizures in people with neurocysticercosis (NCC). Although antihelminthic treatment is effective in eliminating viable cysts and possibly cysticercus granulomas, its effect on seizure outcome remains uncertain. Corticosteroids and combinations of antihelminthic and corticosteroid treatments reduce the incidence of seizures in the short term at least. Although antiepileptic drugs (AEDs) are routinely employed in the treatment of seizures associated with NCC, there is no clear consensus regarding the choice and optimal duration of AED treatment. Long-term AED treatment is warranted in people with calcific residue following involution of brain parenchymal cysticercosis. This article is part of a Special Issue entitled "Neurocysticercosis and Epilepsy".

Neurocysticercosis: Diagnostic problems & current therapeutic strategies

Neurocysticercosis (NCC) is the most common single cause of seizures/epilepsy in India and several other endemic countries throughout the world. It is also the most common parasitic disease of the brain caused by the cestode Taenia solium or pork tapeworm. The diagnosis of NCC and the tapeworm carrier (taeniasis) can be relatively inaccessible and expensive for most of the patients. In spite of the introduction of several new immunological tests, neuroimaging remains the main diagnostic test for NCC. The treatment of NCC is also mired in controversy although, there is emerging evidence that albendazole (a cysticidal drug) may be beneficial for patients by reducing the number of seizures and hastening the resolution of live cysts. Currently, there are several diagnostic and management issues which remain unresolved. This review will highlight some of these issues.

Severe seizures in pigs naturally infected with Taenia solium in Tanzania

•

Pigs with neurocysticercosis can develop clinical signs and suffer from seizures.

•

Autonomic signs were chewing motions with foamy salivation and ear stiffening.

•

Motor signs included tonic muscle contractions and tremor.

•

Stereotypic walking in circles was observed on several occasions.

Neurocysticercosis (NCC) caused by Taenia solium is a serious neurological disease. In humans neurological symptoms have been thoroughly studied and documented, however, there is limited information on clinical signs in pigs infected with T. solium cysticerci. Among the scientific community, it is in fact believed that pigs with NCC rarely show neurological signs. The aim of this study was to describe clinical manifestations associated with NCC in pigs and correlate the manifestations to the number and distribution of cysticerci in brains of naturally infected pigs in Tanzania. Sixteen infected and 15 non-infected control pigs were observed for 14 days during daylight hours, and subsequently videotaped for another 14 consecutive days using close circuit television cameras. All occurrences of abnormal behaviour (trembling, twitching, mouth and ear paralysis, ataxia, dribbling, salivating, eye blinking, walking in circles) were recorded. At the end of the recording period, pigs were slaughtered and their brains dissected, cysticerci counted and locations noted. During the recording period, two infected pigs were observed having seizures. Some of the observed autonomic signs during a seizure were chewing motions with foamy salivation and ear stiffening. Motor signs included tonic muscle contractions followed by a sudden diminution in all muscle function leading to collapse of the animal. Stereotypic walking in circles was observed on several occasions. At dissection, both pigs had a high number of brain cysticerci (241 and 247 cysticerci). The two pigs with seizures were also older (36 months) compared to the others (18.3 months, ± 8.2 standard deviation). Results of this study have shown that pigs with NCC can develop clinical signs and suffer from seizures like humans with symptomatic NCC. Results of this study could potentially open up a new experimental pathway to explore the aetiology of neurological symptoms in humans with NCC associated epilepsy.

Albendazole and Corticosteroids for the Treatment of Solitary Cysticercus Granuloma: A Network Meta-analysis

Background

Solitary cysticercus granuloma (SCG) is the commonest form of neurocysticercosis in the Indian subcontinent and in travelers. Several different treatment options exist for SCG. We conducted a Bayesian network meta-analysis of randomized clinical trials (RCTs) to identify the best treatment option to prevent seizure recurrence and promote lesion resolution for patients with SCG.

Methods and Principal Findings

PubMed, EMBASE and the Cochrane Library databases (up to June 1, 2015) were searched for RCTs that compared any anthelmintics or corticosteroids, alone or in combination, with placebo or head to head and reported on seizure recurrence and lesion resolution in patients with SCG. A total of 14 RCTs (1277 patients) were included in the quantitative analysis focusing on four different treatment options. A Bayesian network model computing odds ratios (OR) with 95% credible intervals (CrI) and probability of being best (P_best) was used to compare all interventions simultaneously. Albendazole and corticosteroids combination therapy was the only regimen that significantly decreased the risk of seizure recurrence compared with conservative treatment (OR 0.32, 95% CrI 0.10–0.93, P_best 73.3%). Albendazole and corticosteroids alone or in combination were all efficacious in hastening granuloma resolution, but the combined therapy remained the best option based on probability analysis (OR 3.05, 95% CrI 1.24–7.95, P_best 53.9%). The superiority of the combination therapy changed little in RCTs with different follow-up durations and in sensitivity analyses. The limitations of this study include high risk of bias and short follow-up duration in most studies.

Conclusions

Dual therapy of albendazole and corticosteroids was the most efficacious regimen that could prevent seizure recurrence and promote lesion resolution in a follow-up period of around one year. It should be recommended for the management of SCG until more high-quality evidence is available.

Neurocysticercosis is an infection of the central nervous system by the larva of Taenia solium (pork tapeworm). It is a leading cause of epilepsy in the world. The disease takes many different forms, each with different optimal treatment. In this study, we focused on the treatment of solitary cysticercus granuloma (SCG), previous evidence on which is inconclusive. Since many different regimens have been compared in clinical trials of SCG, we conducted a network meta-analysis. This method is powerful as it can analyze quantitatively all of the data from all comparisons together. The result can tell us how different treatments perform against each other and how treatments should be ranked. The outcomes of our meta-analysis suggest that the combination of albendazole and corticosteroids is the most efficacious regimen to control seizures in affected patients and to promote the total disappearance of the lesion, compared with albendazole alone, corticosteroids alone, and conservative treatment.

Single small enhancing CT Lesions, with special reference to neurocysticercosis: How I treat

Single small enhancing CT lesions (SSECTL) have been very commonly encountered in clinical practice. These lesions typically are small (often < 20 mm), enhancing as a ring lesion or a disc and with varying amounts of surrounding edema. Most SSECTL present as focal seizures. Once the diagnosis of SSECTL and likely to be a solitary cysticercus lesion is made, the patient is given appropriate AED therapy. Depending on the resolution pattern on repeat imaging performed at intervals not less than six months if patient remains asymptomatic, cysticidal therapy is instituted along with AEDs. Any deviation from the classical clinical or radiological patterns needs further evaluation and other etiologies described for the SSECTL will need to be ruled out, including that of tuberculosis. Largely these lesions resolve and the clinical condition remains benign and in most patients AEDs can be withdrawn in two to three years period.

Neurocysticercosis: an update

Neurocysticercosis (NCC) is the most common helminthic disease of the nervous system in humans and a major cause of acquired epilepsy worldwide. The presentation of the disease is dependent on both the immunological response of the host against the parasite as well as the location of the encysted organisms within the central nervous system (CNS). The principles of management utilized for intraparenchymal disease cannot be applied to extraparenchymal NCC. An advance in management of intraparenchymal NCC, the most common form encountered by physicians, is the use of both albendazole and praziquantel as a treatment strategy. Patients with subarachnoid NCC (SANCC) require months of treatment with both an antiparasitic agent and steroids to avoid complications such as hydrocephalus and vascular events during treatment. The determinants of successful treatment in SANCC have not been established, but response to therapy can be determined by evaluating several endpoints related to disease evolution including radiographic changes, serum antigen, and CSF antigen. Intraventricular NCC is primarily a surgical disease and data supports minimally invasive endoscopic removal of cysts in many of these patients. NCC is increasingly recognized in non-endemic countries due to increased immigration making it important for physicians to become familiar with the management of this disease.

Clinical management of neurocysticercosis

Neurocysticercosis is the most common helminthic disease of the nervous system and a leading cause of acquired epilepsy worldwide. Differences in the number and location of lesions as well as in the severity of the immune response against the parasites, makes neurocysticercosis a complex disease. Therefore, a single therapeutic approach is not expected to be useful in every patient. Introduction of cysticidal drugs - praziquantel and albendazole - have changed the prognosis of thousands of patients with neurocysticercosis. While pioneer trials of therapy were flawed by a poor design, recent studies have shown that cysticidal drugs results in disappearance of lesions and clinical improvement in most cases. Nevertheless, some patients with parenchymal neurocysticercosis may be left with remaining cysts and may develop recurrent seizures after therapy, and many patients with subarachnoid cysts may need repeated courses of therapy. In addition, not all forms of the disease benefit from cysticidal drugs.

Central Nervous System Infections

Central nervous system (CNS) infections—i.e., infections involving the brain (cerebrum and cerebellum), spinal cord, optic nerves, and their covering membranes—are medical emergencies that are associated with substantial morbidity, mortality, or long-term sequelae that may have catastrophic implications for the quality of life of affected individuals. Acute CNS infections that warrant neurointensive care (ICU) admission fall broadly into three categories—meningitis, encephalitis, and abscesses—and generally result from blood-borne spread of the respective microorganisms. Other causes of CNS infections include head trauma resulting in fractures at the base of the skull or the cribriform plate that can lead to an opening between the CNS and the sinuses, mastoid, the middle ear, or the nasopharynx. Extrinsic contamination of the CNS can occur intraoperatively during neurosurgical procedures. Also, implanted medical devices or adjunct hardware (e.g., shunts, ventriculostomies, or external drainage tubes) and congenital malformations (e.g., spina bifida or sinus tracts) can become colonized and serve as sources or foci of infection. Viruses, such as rabies, herpes simplex virus, or polioviruses, can spread to the CNS via intraneural pathways resulting in encephalitis. If infection occurs at sites (e.g., middle ear or mastoid) contiguous with the CNS, infection may spread directly into the CNS causing brain abscesses; alternatively, the organism may reach the CNS indirectly via venous drainage or the sheaths of cranial and spinal nerves. Abscesses also may become localized in the subdural or epidural spaces. Meningitis results if bacteria spread directly from an abscess to the subarachnoid space. CNS abscesses may be a result of pyogenic meningitis or from septic emboli associated with endocarditis, lung abscess, or other serious purulent infections. Breaches of the blood–brain barrier (BBB) can result in CNS infections. Causes of such breaches include damage (e.g., microhemorrhage or necrosis of surrounding tissue) to the BBB; mechanical obstruction of microvessels by parasitized red blood cells, leukocytes, or platelets; overproduction of cytokines that degrade tight junction proteins; or microbe-specific interactions with the BBB that facilitate transcellular passage of the microorganism. The microorganisms that cause CNS infections include a wide range of bacteria, mycobacteria, yeasts, fungi, viruses, spirochaetes (e.g., neurosyphilis), and parasites (e.g., cerebral malaria and strongyloidiasis). The clinical picture of the various infections can be nonspecific or characterized by distinct, recognizable clinical syndromes. At some juncture, individuals with severe acute CNS infections require critical care management that warrants neuro-ICU admission. The implications for CNS infections are serious and complex and include the increased human and material resources necessary to manage very sick patients, the difficulties in triaging patients with vague or mild symptoms, and ascertaining the precise cause and degree of CNS involvement at the time of admission to the neuro-ICU. This chapter addresses a wide range of severe CNS infections that are better managed in the neuro-ICU. Topics covered include the medical epidemiology of the respective CNS infection; discussions of the relevant neuroanatomy and blood supply (essential for understanding the pathogenesis of CNS infections) and pathophysiology; symptoms and signs; diagnostic procedures, including essential neuroimaging studies; therapeutic options, including empirical therapy where indicated; and the perennial issue of the utility and effectiveness of steroid therapy for certain CNS infections. Finally, therapeutic options and alternatives are discussed, including the choices of antimicrobial agents best able to cross the BBB, supportive therapy, and prognosis.

Drug therapy for solitary cysticercus granuloma: a systematic review and meta-analysis

OBJECTIVE

The effectiveness of anthelminthic and corticosteroid drug therapy in parenchymal neurocysticercosis is well established. The treatment of parenchymal solitary cysticercus granuloma (SCG), however, remains controversial. We attempted to obtain a consistent estimate of the efficacy of anthelminthic and corticosteroid drug treatment in SCG.

METHODS

Randomized-controlled trials (RCTs) comparing rates of seizure freedom, granuloma resolution, and residual calcification in individuals with SCG treated with anthelminthic or corticosteroid drugs with those treated with antiepileptic drugs (AEDs) alone were systematically reviewed and quantified using fixed- or random-effects meta-analysis.

RESULTS

Fifteen RCTs were identified for inclusion. Ten RCTs assigned 765 people with SCG to AED treatment with or without anthelminthic drug (albendazole) treatment. A further 5 RCTs assigned 457 people with SCG to AED treatment with or without corticosteroid drugs. Anthelminthic treatment was associated with significantly increased rates of seizure freedom (nonevent odds ratio: 2.45; 95% confidence interval: 1.49-4.03; p = 0.0004) and significantly higher rates of granuloma resolution (odds ratio: 2.09; 95% confidence interval: 1.41-3.00; p = 0.0003), but did not alter the risk of residual calcification. Corticosteroid treatment was not significantly associated with any outcome.

CONCLUSIONS

Anthelminthic treatment with albendazole provides improved rates of seizure freedom and hastens resolution of the granuloma. The role of corticosteroid treatment remains uncertain. The benefits (or lack thereof in the case of corticosteroids) are consistent when measured across different time points after treatment.

Medical management of neurocysticercosis

INTRODUCTION

Neurocysticercosis (NCC) is considered to be the most common cause of acquired epilepsy worldwide. Formerly restricted to palliative measures, therapy for NCC has advanced with the advent of two drugs that are considered to be effective: praziquantel (PZQ) and albendazole (ALB).

AREAS COVERED

All available articles regarding research related to the treatment of NCC were searched. Relevant articles were then reviewed and used as sources of information for this review.

EXPERT OPINION

Anticysticercal therapy has been marked by intense controversy. Recent descriptions of spontaneous resolution of parenchymal cysticercosis with benign evolution, risks of complications and reports of no long-term benefits have reinforced the debate over the usefulness and safety of anticysticercal therapy. High interindividual variability and complex pharmacological interactions will require the close monitoring of plasma concentrations of ALB and PZQ metabolites in future trials. Given the relative scarcity of clinical trials, more comparative interventional studies - especially randomized controlled trials in long-term clinical evolution - are required to clarify the controversy over the validity of parasitic therapy in patients with NCC.

Diagnosis and treatment of neurocysticercosis

Neurocysticercosis is a parasitic disease caused by the larval (cystic) form of the pork cestode tapeworm, Taenia solium, and is a major cause of acquired seizures and epilepsy worldwide. Development of sensitive and specific diagnostic methods, particularly CT and MRI, has revolutionized our knowledge of the burden of cysticercosis infection and disease, and has led to the development of effective antihelminthic treatments for neurocysticercosis. The importance of calcified granulomas with perilesional edema as foci of seizures and epilepsy in populations where neurocysticercosis is endemic is newly recognized, and indicates that treatment with anti-inflammatory agents could have a role in controlling or preventing epilepsy in these patients. Importantly, neurocysticercosis is one of the few diseases that could potentially be controlled or eliminated-an accomplishment that would prevent millions of cases of epilepsy. This Review examines the rationale for treatment of neurocysticercosis and highlights the essential role of inflammation in the pathogenesis of disease, the exacerbation of symptoms that occurs as a result of antihelminthic treatment, and the limitations of current antihelminthic and anti-inflammatory treatments.

Short-course of prednisolone in solitary cysticercus granuloma: a randomized, double-blind, placebo-controlled trial

PURPOSE

To determine the effect of administration of a short course of prednisolone on seizure and radiologic outcome in patients with solitary cysticercus granuloma (SCG).

METHODS

One hundred forty-eight subjects presenting with new-onset seizures (<15 days duration) and with SCG demonstrated on imaging studies were randomly allocated to either treatment with prednisolone (40-60 mg/day for 2 weeks) or placebo in addition to standard antiepileptic drug therapy. The subjects were followed up for seizure recurrence for 9 months. Repeat computed tomography (CT, at 3 months) and magnetic resonance imaging (MRI, at 6 months) to evaluate resolution and calcification of the lesion.

KEY FINDINGS

There was no difference in the proportion of subjects with seizure recurrence during the follow-up period in the treatment (n = 16, 21.9%) and control (n = 19, 25.33%) groups (p = 0.7). However, generalized seizures occurred in a significantly lesser proportion of subjects in the treatment group (n = 3, 15.79%) in comparison to the control group (n = 12, 60.00%) (p = 0.015). There were no significant differences in the proportion of subjects with complete resolution of the SCG on repeat CT at 3 months [treatment group (27, 46.7%) and control group (23, 39.8%); p = 0.453] and repeat MRI at 6 months [treatment group (28, 46.7%) and control group (21, 38.9%); p = 0.402].

SIGNIFICANCE

The administration of a short course of prednisolone does not offer significant improvement in seizure control, although a benefit in terms of reducing the likelihood of generalized seizures is possible. Furthermore, it does not improve the chances of resolution of the SCG on follow-up imaging studies.

Neurocysticercosis

Neurocysticercosis (NCC) is the most common cause of acquired epilepsy in developing countries. It can present variably depending on the location and stage of cysts in the nervous system, and the host immune response. The most common presentation of parenchymal NCC is with seizures that are usually focal and brief; status epilepticus occurs in some cases. About a third of cases have headache and vomiting. Diagnosis is made by either CT or MRI. Single, small, contrast enhancing lesions are the most common; visualization of a scolex is diagnostic. Some cases have multiple cysts with a characteristic starry-sky appearance. Although treatment with cysticidal therapy continues to be debated, there is increasing evidence that it helps through increased and faster resolution of CT lesions; whether there is any improvement in long-term seizure control needs further study. It should not be used in cysticercus encephalitis or in ophthalmic NCC and used with caution in extraparenchymal NCC. It is of no use in calcified lesions. Corticosteroids are used simultaneously to reduce cerebral oedema. Seizures respond well to a single antiepileptic, and the seizure recurrence rate is low in cases with single lesions; those with multiple, persistent or calcified lesions usually have recurrent seizures. Extraparenchymal NCC is often associated with intracranial hypertension, hydrocephalous and chronic meningitis; it has a guarded prognosis; surgical intervention is required in many cases. Management of NCC needs to be individualized. NCC is potentially eradicable; proper sanitation, hygiene and animal husbandry are warranted.

A diagnostic and therapeutic scheme for a solitary cysticercus granuloma

BACKGROUND

Solitary cysticercus granuloma (SCG) is one of the most common forms of presentation of neurocysticercosis (NCC). The diagnostic workup and management approach to this condition remain uncertain and controversial.

OBJECTIVE

To review evidence and develop a consensus approach to the diagnosis and treatment of SCG.

METHODS

A multidisciplinary expert group meeting was convened in order to review and discuss various aspects of management of patients with SCG. Evidence reviewed was classified and a consensus was evolved according to standard protocols.

RESULTS

SCG is commonly recognized on CT as an enhancing lesion measuring <20 mm. Further evaluation with MRI does not add much information. The use of antihelminthic agents (specifically, albendazole in combination with corticosteroids) and corticosteroids alone have been shown to improve radiologic resolution and seizure outcome in patients with SCG. However, the sizes of the effects are modest. By convention, all patients with SCG presenting with seizures are initiated on antiepileptic drugs (AEDs). Available evidence suggests that withdrawal of AEDs after complete resolution of the SCG is safe. There is a high risk of seizure relapse after AED withdrawal in patients with calcific residue following resolution of the SCG. The duration of AED prophylaxis in these individuals is unclear.

CONCLUSIONS

It is desirable to have large, multicenter trials with sufficiently long follow-up, comparing outcomes with the use of antihelminthics with or without corticosteroids and corticosteroids alone in order to dissect out the benefits accrued due to each of these classes of drugs.

Anthelmintics for people with neurocysticercosis

BACKGROUND

Neurocysticercosis is an infection of the brain by the larval stage of the pork tapeworm. In endemic areas it is a common cause of epilepsy. Anthelmintics (albendazole or praziquantel) may be given to kill the parasites. However, there are potential adverse effects, and the parasites may eventually die without treatment.

OBJECTIVES

To assess the effectiveness and safety of anthelmintics for people with neurocysticercosis.

SEARCH STRATEGY

In May 2009 we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE, EMBASE, LILACS, and the mRCT.

SELECTION CRITERIA

Randomized controlled trials comparing anthelmintics with placebo, no anthelmintic, or other anthelmintic regimen for people with neurocysticercosis.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data, and assessed each trial's risk of bias. We calculated risk ratios (RR) for dichotomous variables, with 95% confidence intervals (CI). We pooled data from trials with similar interventions and outcomes.

MAIN RESULTS

For viable lesions in children, there were no trials. For viable lesions in adults, no difference was detected for albendazole compared with no treatment for recurrence of seizures (116 participants, one trial); but fewer participants with albendazole had lesions at follow up (RR 0.56, 95% CI 0.45 to 0.70; 192 participants, two trials).For non-viable lesions in children, seizures recurrence was less common with albendazole compared with no treatment (RR 0.49, 95% CI 0.32 to 0.75; 329 participants, four trials). There was no difference detected in the persistence of lesions at follow up (570 participants, six trials). For non-viable lesions in adults, there were no trials.In trials including viable, non-viable or mixed lesions (in both children and adults), headaches were more common with albendazole alone (RR 9.49, 95% CI 1.40 to 64.45; 106 participants, two trials), but no difference was detected in one trial giving albendazole with corticosteroids (116 participants, one trial).

AUTHORS' CONCLUSIONS

In patients with viable lesions, evidence from trials of adults suggests albendazole may reduce the number of lesions. In trials of non-viable lesions, seizure recurrence was substantially lower with albendazole, which is counter-intuitive. It may be that steroids influence headache during treatment, but further research is needed to test this.

Anthelmintics for people with neurocysticercosis

BACKGROUND

Neurocysticercosis is an infection of the brain by the larval stage of the pork tapeworm. In endemic areas it is a common cause of epilepsy. Anthelmintics (albendazole or praziquantel) may be given to kill the parasites. However, there are potential adverse effects, and the parasites may eventually die without treatment.

OBJECTIVES

To assess the effectiveness and safety of anthelmintics for people with neurocysticercosis.

SEARCH STRATEGY

In May 2009 we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and the mRCT.

SELECTION CRITERIA

Randomized controlled trials comparing anthelmintics with placebo, no anthelmintic, or other anthelmintic regimen for people with neurocysticercosis.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data, and assessed each trial's risk of bias. We calculated risk ratios (RR) for dichotomous variables, with 95% confidence intervals (CI). We pooled data from trials with similar interventions and outcomes.

MAIN RESULTS

For viable lesions in children, there were no trials. For viable lesions in adults, no difference was detected for albendazole compared with no treatment for recurrence of seizures (116 participants, one trial); but fewer participants with albendazole had lesions at follow up (RR 0.56, 95% CI 0.45 to 0.70; 192 participants, two trials).For non-viable lesions in children, seizures recurrence was less common with albendazole compared with no treatment (RR 0.49, 95% CI 0.32 to 0.75; 329 participants, four trials). There was no difference detected in the persistence of lesions at follow up (570 participants, six trials). For non-viable lesions in adults, there were no trials.In trials including viable, non-viable or mixed lesions (in both children and adults), headaches were more common with albendazole alone (RR 9.49, 95% CI 1.40 to 64.45; 106 participants, two trials), but no difference was detected in one trial giving albendazole with corticosteroids (116 participants, one trial).

AUTHORS' CONCLUSIONS

In patients with viable lesions, evidence from trials of adults suggests albendazole may reduce the number of lesions. In trials of non-viable lesions, seizure recurrence was substantially lower with albendazole, which is counter-intuitive. It may be that steroids influence headache during treatment, but further research is needed to test this.

Diagnosis and treatment of neurocysticercosis

Neurocysticercosis, the infection caused by the larval form of the tapeworm Taenia solium, is the most common parasitic disease of the central nervous system and the most common cause of acquired epilepsy worldwide. This has primarily been a disease that remains endemic in low-socioeconomic countries, but because of increased migration neurocysticercosis is being diagnosed more frequently in high-income countries. During the past three decades improved diagnostics, imaging, and treatment have led to more accurate diagnosis and improved prognosis for patients. This article reviews the current literature on neurocysticercosis, including newer diagnostics and treatment developments.

Neurocysticercosis in children

Neurocysticercosis (NCC) is a common cause of seizures and neurologic disease. Although there may be variable presentations depending on the stage and location of cysts in the nervous system, most children (> 80%) present with seizures particularly partial seizures. About a third of cases have headache and vomiting. Diagnosis is made by either CT or MRI. Single enhancing lesions are the commonest visualization of a scolex confirms the diagnosis. Some cases have multiple cysts with a characteristic starry-sky appearance. Management involves use of anticonvulsants for seizures and steroids for cerebral edema. The use of cysticidal therapy continues to be debated. Controlled studies have shown that cysticidal therapy helps in increased and faster resolution of CT lesions. Improvement in long-term seizure control has not yet been proven. Children with single lesions have a good outcome and seizure recurrence rate is low. Children with multiple lesions have recurrent seizures. Extraparenchymal NCC has a guarded prognosis but it is rare in children. In endemic areas NCC must be considered in the differential diagnosis of seizures and various other neurological disorders.

WITHDRAWN: Drugs for treating neurocysticercosis (tapeworm infection of the brain)

BACKGROUND

Anthelminthic drugs may shrink brain cysts in neurocysticercosis, but can also cause severe adverse effects.

OBJECTIVES

The objective of this review was to assess the effects of drug treatment in human neurocysticercosis in relation to survival, cyst persistence, subsequent seizures and hydrocephalus.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group specialized trials register (September 2002), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to August 2002), LILACS (September 2002). We contacted researchers and experts in the field, and pharmaceutical companies.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing a cysticidal drug with a placebo or a control group receiving symptomatic therapy, in patients with neurocystercosis.

DATA COLLECTION AND ANALYSIS

Assessment of trial quality and data extraction was done independently by two reviewers.

MAIN RESULTS

Four studies involving 305 people met the inclusion criteria. None reported on withdrawal of anticonvulsant therapy, headache relief, disability or death as outcomes. A difference just approaching significance was detected between cysticidal therapy and placebo in relation to cyst persistence up to six months (relative risk 0.83, 95% confidence interval 0.70 to 0.99). Two trials reported on seizures after one to two years follow-up and found no difference (relative risk 0.95, 95% 0.59 to 1.51). There was no difference detected for hydrocephalus (relative risk 2.19, 95% confidence interval 0.29 to 16.55).

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess whether cysticidal therapy in neurocysticerosis is associated with beneficial effects.

Treatment of neurocysticercosis: current status and future research needs

Here we put forward a roadmap that summarizes important questions that need to be answered to determine more effective and safer treatments. A key concept in management of neurocysticercosis is the understanding that infection and disease due to neurocysticercosis are variable and thus different clinical approaches and treatments are required. Despite recent advances, treatments remain either suboptimal or based on poorly controlled or anecdotal experience. A better understanding of basic pathophysiologic mechanisms including parasite survival and evolution, nature of the inflammatory response, and the genesis of seizures, epilepsy, and mechanisms of anthelmintic action should lead to improved therapies.

Intravenous methyl prednisolone in patients with solitary cysticercus granuloma: A random evaluation

PURPOSE

To evaluate the role of intravenous methyl prednisolone in patients with solitary cysticercus granuloma with new-onset seizures.

METHODS

In this open-label, randomized, prospective, follow-up study, 52 patients with new-onset seizures and a single enhancing CT lesion of cysticercus were randomly divided in two groups to receive either intravenous methyl prednisolone for 5 days along with antiepileptic drug (n=25) or antiepileptic drug monotherapy (n=27) alone. The patients were followed up for at least for 9 months. Repeat CT scans were performed after 2 months.

RESULTS

After 2 months, lesion disappeared in 60% patients of intravenous methyl prednisolone group and 18.5% patients receiving only antiepileptic drug (p=0.001). As far as seizure recurrence was concerned, a lower number (16% versus 33%) of intravenous methyl prednisolone treated patient had recurrence, the difference was insignificant.

CONCLUSION

Intravenous methyl prednisolone therapy helps in early resolution of solitary cysticercus granuloma.

Short course of prednisolone in patients with solitary cysticercus granuloma: a double blind placebo controlled study

The study was conducted to confirm the role of a short course of oral corticosteroids in patients with solitary cysticercus granuloma with seizures by a double-blind placebo-controlled study. In an open-label trial we, in past, had demonstrated a beneficial role of prednisolone. A short course of prednisolone helped in early resolution of solitary cysticercus granuloma. In this double-blind placebo-controlled randomized study, 60 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either anti-epileptic monotherapy with prednisolone (n=30) or anti-epileptic monotherapy along with placebo (n=30). The patients received prednisolone, 1mg/kg/day for 10 days, followed by tapering over next 4 days. None of the patients received albendazole therapy. The patients were followed up monthly, at least for 9 months. A repeat CT scan was performed after 6 months. The data were analysed by chi-square test. The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 6 months demonstrated non-significantly better response for prednisolone treated patients. In prednisolone group the lesion disappeared in 52% of patients and in 48% patients who received placebo. However, a significantly lesser number of prednisolone treated patients (n=12%) than controls (n=48%), had seizure recurrence. Our study suggests that short-term prednisolone therapy may not help in rapid resolution of solitary cysticercus granuloma, however, prednisolone therapy improves seizure-related prognosis.

Neurocysticercosis: updated concepts about an old disease

Neurocysticercosis, the infection of the human brain by the larvae of Taenia solium, is a major cause of acquired epilepsy in most low-income countries. Cases of neurocysticercosis are becoming more common in high-income countries because of increased migration and travel. Diagnosis by neuroimaging and serological assessment has greatly improved over the past decade, and the natural progression of the disease and response to antiparasitic drugs is now much better understood. Neurocysticercosis is potentially eradicable, and control interventions are underway to eliminate this infection. Meanwhile, updated information on diagnosis and management of neurocysticercosis is required, especially for clinicians who are unfamiliar with its wide array of clinical presentations.

Prednisolone-responsive headache in patients with solitary cysticercus granuloma and seizures

BACKGROUND

Solitary cysticercus granuloma is the commonest imaging abnormality in Indian patients with new-onset seizures. Few patients, in addition, complain of disabling headache.

OBJECTIVE

To report our experience of 16 patients with new-onset headache, seizures, and solitary cysticercus granuloma.

METHODS

Sixteen consecutive patients, who had moderate to severe new-onset headache and fulfilled the diagnostic criteria of solitary cysticercus granuloma, were included in the study. The inclusion criteria were: occurrence of seizures, minimal or no neurologic deficit, absence of papilledema, no evidence of any systemic disorder, and computed tomography showing a single ring/disk-enhancing lesion of <20 mm in diameter. Patients received antiepileptic monotherapy, oral analgesics, and prednisolone (1.5 mg/kg/day for 7 days). Prednisolone was then tapered over the next 7 days. Patients were followed for 6 months. Follow-up computed tomography was performed after 2 months; in all 16 patients, the scans showed complete disappearance of the lesion.

RESULTS

After 14 days (at first follow-up), all patients reported significant improvement in headache. Follow-up after 2 months revealed that all patients were headache-free. None of the patients reported any recurrence of headache.

CONCLUSION

This open-label study suggests the effectiveness of prednisolone for disabling headache in Indian patients with solitary cysticercus granuloma and seizures. There is a need, however, for more scientifically rigorous studies for further confirmation of our results.

Neurocysticercosis in children

Neurocysticercosis is a major cause of neurologic disease worldwide. The clinical presentations are pleomorphic depending on the stage and location of cysts in the nervous system. Most children (> 80%) present with seizures, particularly partial seizures; headache and vomiting are seen in about a third of cases. Diagnosis is made by either computed tomography (CT) or magnetic resonance imaging. Single enhancing lesions are the most common finding. Visualization of a scolex confirms the diagnosis. Some cases have multiple cysts; the "starry-sky" appearance in cases with innumerable cysts is characteristic. Most children require anticonvulsants. Corticosteroids are indicated in those with cerebral edema. The efficacy of cysticidal therapy continues to be debated. Controlled studies suggest that cysticidal therapy helps in increased and faster resolution of CT lesions, but there is no conclusive evidence that it improves long-term seizure control. The prognosis in cases with single lesions is good; seizure control is achieved with a single anticonvulsant, and the recurrence rate is low. Children with multiple lesions have recurrent seizures. Extraparenchymal neurocysticercosis is rare in children and carries a poor prognosis. Neurocysticercosis must be considered in the differential diagnosis of seizures and a wide variety of neurologic disorders, particularly in endemic areas.

Corticosteroids versus albendazole for treatment of single small enhancing computed tomographic lesions in children with neurocysticercosis

Single small enhancing computed tomographic (CT) lesions representing cysticercus granuloma are a common cause of focal seizures in children. Controversy exists regarding the efficacy of various modalities of treatment. We conducted a randomized prospective trial to evaluate the efficacy of corticosteroids, albendazole, and corticosteroids with albendazole in children with focal seizures and single small enhancing CT lesions. The study population consisted of 133 children with focal seizures of recent onset (< 3 months) and single small enhancing CT lesions who presented to the Neurocysticercosis Clinic of Pediatric Neurology Services at the Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, an urban teaching and tertiary care hospital in Chandigarh, North India. All children were randomly assigned to receive corticosteroids (group S), albendazole (group A), or both corticosteroids and albendazole (group SA) for 28 days. CT was done at 3 and 6 months after enrollment in the study. Of the 133 patients enrolled, 23 were lost to follow-up. Of the remaining 110 patients, 38 patients were in group S, 37 in group A, and 35 in group SA. All children were followed up for at least 18 months. Disappearance of the lesion on CT scan was noted in 52.6% of patients in group S, 59.5% in group A, and 62.9% in Group SA (P > .1) at the 3-month follow-up. After the 6-month follow-up, disappearance of the lesion was noted in 76.3% in group S, 75.7% in group A, and 74.2% in group SA (P > .1). Twenty-three patients had seizure recurrence while on antiepilepsy drugs: 36.8% of patients in group S, 13.5% in group A, and 11.4% in group SA (P < .05). Seizure recurrence after antiepilepsy drug withdrawal was seen in seven children (three in group S and two each in groups A and SA). In conclusion, there was no significant difference in resolution of CT lesions in the three therapy groups at 3 and 6 months of follow-up. Children in the corticosteroid group had significantly more seizure recurrences while on antiepilepsy drugs.

Solitary cerebral cysticercus granuloma

Solitary cerebral cysticercus granuloma (SCCG) is one of the commonest causes of seizures in Indian patients. SCCG has been confused in the past with tuberculomas, but by applying a set of diagnostic criteria proposed by the author, they can be diagnosed accurately in the vast majority of patients. Patients with SCCG are managed effectively with antiepileptic drugs (AEDs). The role of cysticidal drugs in their management is controversial. SCCG resolves spontaneously at a variable rate and has a good seizure outcome, with >90% of patients remaining seizure free after discontinuation of AEDs.

Short Course of Prednisolone in Indian Patients with Solitary Cysticercus Granuloma and New-onset Seizures

PURPOSE

To evaluate the role of a short course of oral corticosteroids in Indian patients with solitary cysticercus granuloma with seizures.

METHODS

In this open-label, randomized, prospective follow-up study, 97 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either antiepileptic monotherapy alone (n = 48) or antiepileptic monotherapy with prednisolone (n = 49). The patients in the latter group received prednisolone, 1 mg/kg/day for 10 days, followed by tapering over next 4 days. The patients were followed up for 6 months. Repeated CT scans were performed after 1 and 6 months.

RESULTS

The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 1 and 6 months demonstrated a significantly better response for prednisolone as far as complete resolution of CT lesion was concerned. Kaplan-Meier analysis suggested significantly less probability of seizure recurrence for prednisolone-treated patients. At 6 months, Kaplan-Meier estimated risk of seizure after first seizure was 2% in prednisolone-treated patients in comparison to 13% for those who were not given prednisolone.

CONCLUSIONS

Short-term prednisolone therapy helps in rapid resolution of solitary cysticercus granuloma in Indian patients with new-onset seizures. Resolution of lesions is associated with improved seizure-related prognosis.

Taenia solium cysticercosis

The larval stage of the pork tapeworm (Taenia solium) infects the human nervous system, causing neurocysticercosis. This disease is one of the main causes of epileptic seizures in many less developed countries and is also increasingly seen in more developed countries because of immigration from endemic areas. Little information is available on the natural evolution of taeniasis or cysticercosis. Available therapeutic measures include steroids, treatments for symptoms, surgery, and, more controversially, antiparasitic drugs to kill brain parasites. Efforts to control and eliminate this disease are underway through antiparasitic treatment of endemic populations, development of pig vaccines, and other measures.

Efficacy of albendazole and short-course dexamethasone treatment in children with 1 or 2 ring-enhancing lesions of neurocysticercosis: a randomized controlled trial

OBJECTIVE

To determine the efficacy of albendazole plus dexamethasone in children with 1 or 2 ring-enhancing lesions (by computed tomography scan) on resolution of lesions and recurrence of seizure.

STUDY DESIGN

Randomized controlled open trial.

METHODS

Children of either sex, 1 to 14 years of age, with seizures and 1 or 2 ring-enhancing lesions <20 mm in diameter on computed tomography scan, likely to have neurocysticercosis, were assigned to treatment l groups. Children assigned to the treatment group (n=61) were given 0.15 mg/kg per day dexamethasone for 5 days plus 15 mg/kg per day albendazole for 28 days, starting on the third day of dexamethasone. Control group (n=62) children were given neither dexamethasone or albendazole. Anti-epileptic therapy was given to both the study groups.

RESULTS

The lesions resolved completely or partially in more children in the treated group compared with the control group (79% versus 57%; P=.02). The proportion of children who had seizures was significantly lower in the treated group compared with the control group at 3 months (10% versus 32%; P=.006) and 6 months (13% versus 33%; P=.03).

CONCLUSIONS

Albendazole plus dexamethasone increased complete or partial resolution of lesions and reduced the risk of subsequent recurrence of seizures among children with neurocysticercosis who had with seizures and 1 or 2 ring-enhancing lesions on computed tomography.

Neurocysticercosis in children: clinical findings and response to albendazole therapy in a randomized, double-blind, placebo-controlled trial in newly diagnosed cases

The clinical findings of neurocysticercosis, diagnosed primarily on the basis of computed tomography (CT), and response to albendazole therapy in a randomized, double-blind, placebo-controlled trial were studied in 72 newly diagnosed children aged 1.5-12 years admitted to hospital in New Delhi, India, during March to July 2000. The lesions by initial CT were mostly single with perilesional oedema, and were located in the parietal lobes. The most common clinical finding was partial seizure (79.2%). The outcome of the albendazole trial was assessed through changes in CT lesions and status of seizure after 6 months of follow-up; about 55% of the lesions had disappeared and about 80% of the children were seizure-free. The frequency of healing of CT lesions in the albendazole-treated group and placebo group was 54.2% and 55.2%, respectively, and the frequency of a seizure-free state in the albendazole-treated group and placebo group was 87.5% and 77.5%, respectively; the differences were not statistically significant. Changes in lesions by CT and the recurrence of seizures after 6 months of follow-up were not related to the number of lesions by initial CT and albendazole was not beneficial in neurocysticercosis in children with ring-enhancing lesions in CT.

Human case management and treatment of cysticercosis

Disease manifestations due to neurocysticercosis vary markedly and depend upon the location, size and number of cysts as well as the viability or degeneration of cysts and presence, type and degree of host response. Accordingly, the clinical management for each patient should be individualized. Treatment modalities include: (1) larvicidal drugs such as albendazole or praziquantel in patients with viable cysts; (2) corticosteroids or other agents to suppress or prevent the host's immune response; (3) anti-seizure medication(s) to treat or prevent recurrent seizures; (4) surgical interventions; and (5) the use of supportive family, social or health agencies in impaired individuals. Although it is known that larvicidal treatment kills viable cysts that commonly resolve or calcify, the clinical benefit of this treatment in the most common presentations is unproven. However, medical treatment of giant subarachnoid cysts, large parenchymal cysts or orbital cysts causing mass effect has led to definite clinical improvement in uncontrolled trials. Whether there is faster radiological improvement and/or clinical benefit in the treatment of cysts showing signs of inflammation by magnetic resonance imaging (enhancement and/or edema) is like-wise controversial. There is no general understanding when or how to use corticosteroids to suppress natural or treatment-induced inflammation around cysts although their use when inflammation contributes or could be expected to cause undue morbidity or mortality is reasonable. Anti-seizure medication should usually be employed in patients with seizures or patients who may likely develop seizures. Surgical intervention is required to alleviate mass effect, remove some cysts causing obstruction of the ventricles, shunt placement for hydrocephalus, and sometimes for removal and/or decompression of large or critically located cysts before larvicidal treatment.

An unusual cause of seizures after cardiopulmonary bypass

IMPLICATIONS

We present a case of a 34-yr-old woman who developed seizures after an open-heart procedure requiring cardiopulmonary bypass. The seizures were most likely caused by previously undiagnosed neurocysticercosis and may also have been contributed to by cardiopulmonary bypass.

Neurocysticercosis: an update

Taeniosis and cysticercosis, diseases caused by the parasitic tapeworm Taenia solium, are distributed worldwide where pigs are eaten and sanitation is poor, and also in the more developed countries as a result of increasing migration. Neurocysticercosis is the commonest parasitic disease of the human nervous system. Immunological assays detect positivity for human cysticercosis in 8-12% of people in some endemic regions, which indicates the presence of antibodies against the parasite but not necessarily active or central-nervous-system infection. The only reliable tool for diagnosis of neurocysticercosis is imaging by CT or MRI. The presence of viable cysts with a mural nodule, associated with degenerative cysts and calcifications, is typical. Classification of neurocysticercosis into active, transitional, and inactive forms gives a good clinical-imaging correlation and facilitates medical and surgical treatment. The main clinical manifestations of neurocysticercosis are seizures, headache, and focal neurological deficits, and it can have such sequelae as epilepsy, hydrocephalus, and dementia. Treatment should be individually fitted for each patient, with antiepileptic drugs, analgesics, corticosteroids, or a combination of these. Anthelmintic drugs (praziquantel and albendazole) are used routinely, but so far no controlled clinical trial has established specific indications or definitive doses of treatment. Parenchymal forms of neurocysticercosis have a good prognosis in terms of clinical remission. The most effective approach to taeniosis and cysticercosis is prevention, which should be a primary public-health focus for less developed countries.

Neurocysticercosis in children: clinical characteristics and outcome

A study was undertaken on 176 children with neurocysticercosis to determine the clinical behaviour and long-term outcome of cases. The children were followed up prospectively in the paediatric neurology clinic for 6 years. Diagnosis was based primarily on CT scans. All the CT lesions were parenchymal and mostly single (87%) with ring enhancement and peri-lesional oedema. Partial seizure was the predominant presenting seizure type. About 65% of cases had recurrences at varying intervals during treatment. Albendazole therapy given to some cases did not appear to have any beneficial effect on seizure control. Repeat CTs done at varying intervals after the first seizures showed disappearance of the lesions in about 50% of cases. The majority of lesions disappeared without the use of albendazole. Recurrence of seizures after withdrawal of anti-epileptic medication was observed in 19% of the cases. Parenchymal neurocysticercosis in children commonly presents with partial seizures and ring lesions on CT. The disease can be managed well by anti-epileptic medication alone and the prognosis is good.

Current consensus guidelines for treatment of neurocysticercosis

Taenia solium neurocysticercosis is a common cause of epileptic seizures and other neurological morbidity in most developing countries. It is also an increasingly common diagnosis in industrialized countries because of immigration from areas where it is endemic. Its clinical manifestations are highly variable and depend on the number, stage, and size of the lesions and the host's immune response. In part due to this variability, major discrepancies exist in the treatment of neurocysticercosis. A panel of experts in taeniasis/cysticercosis discussed the evidence on treatment of neurocysticercosis for each clinical presentation, and we present the panel's consensus and areas of disagreement. Overall, four general recommendations were made: (i) individualize therapeutic decisions, including whether to use antiparasitic drugs, based on the number, location, and viability of the parasites within the nervous system; (ii) actively manage growing cysticerci either with antiparasitic drugs or surgical excision; (iii) prioritize the management of intracranial hypertension secondary to neurocysticercosis before considering any other form of therapy; and (iv) manage seizures as done for seizures due to other causes of secondary seizures (remote symptomatic seizures) because they are due to an organic focus that has been present for a long time.

Single enhancing computerized tomography-detected lesion in immunocompetent patients

Single enhancing computerized tomography (CT)-documented lesions may occur in several infectious and neoplastic diseases of the central nervous system and are the most common radiological abnormality seen in patients with acute-onset seizures in India and many other developing countries. Similar CT-documented lesions have also been reported in the developed world where these lesions are often considered to be caused by neoplasms or tuberculoma. Histopathological studies in India and even in some developed countries revealed that neurocysticercosis (NCC) is the most likely cause of these lesions provided they fulfill a rigid set of clinical and radiological criteria. Single cysticercus granuloma measures less than 20 mm in diameter, may be associated with cerebral edema not severe enough to produce midline shift, and occur in patients with seizures, normal neurological status, and no evidence of active systemic disease. When these lesions resolve spontaneously, either disappearing or changing into a calcified nodule, the diagnosis of NCC is very likely. The second most common cause of these CT-detected lesions is tuberculoma; in patients with these lesions similar clinical and neuroimaging features are also present. Few authors believe that in poor and developing countries, where both tuberculosis and NCC are common, it is difficult to differentiate between tuberculoma and a single cysticercal granuloma. The most interesting feature of these solitary enhancing lesions is their spontaneous disappearance within weeks or months. Some lesions "heal" by becoming calcified. These patients require only antiepileptic therapy, and this medication may be withdrawn safely after the lesion has resolved on CT scanning. In several studies provision of anticysticercal drugs has been attempted, but because of conflicting results, their role in the management of these single lesions is uncertain. Neurosurgeons have a very limited role to play. In very rare situations, if the lesion increases in size and if focal neurological deficits manifest or seizures are uncontrolled, a brain biopsy sample may be required and histopathological evaluation performed to establish the correct diagnosis.

Single small enhancing computed tomographic (CT) lesions in Indian patients with new-onset seizures. A prospective follow-up in 75 patients

This study was planned to observe the clinical and radiological course of single small enhancing CT lesions in Indian patients presenting with new-onset-seizures. In this study, 75 patients with new-onset seizures and a single enhancing CT lesion were prospectively followed up for 1 year. All patients fulfilled the criteria of cysticercus granuloma. The repeat CT scans were performed 2 months after the first CT scan. Antiepileptic drug therapy was the only form of treatment given. The majority of patients were below 20 years of age. Simple partial seizure, with or without secondary generalization, was the commonest type of seizure encountered in these patients. In follow-up CT scans 84% of patients showed either disappearance or regression in the size of lesion. The proportion of patients showing complete disappearance of CT lesions was 0.73 (95% CI, 0.61-0.80). In 11 (15%) patients the lesions were calcified. In nine patients, in whom the lesion had persisted or regressed, another follow-up CT scan (6 months after the second scan) revealed either complete disappearance or calcification of the lesions. The majority (86.6%) of patients remained seizure free for 1 year after starting antiepileptic drugs. Ten patients experienced seizure recurrences within the first month of therapy. The proportion of patients who remained seizure free was 0.86 (95% CI, 0.76-0.92). Four patients experienced seizure recurrence even after complete disappearance of CT lesions. In the majority of patients the lesions disappeared spontaneously and in a few the lesions calcified; hence these patients did not require anticysticercal therapy. Antiepileptic therapy was helpful in controlling further recurrences of seizures in most of the patients. A few patients experienced seizures even after disappearance of CT lesions.