Epilepsy and neurocysticercosis in Latin America: a systematic review and meta-analysis

The process of residual calcification following antiparasitic treatment in the pig model of neurocysticercosis is dynamic

BACKGROUND

Calcified neurocysticercosis (NCC), the end stage of brain cysts of the pork tapeworm Taenia solium is a common cause of epilepsy. Calcified NCC lesions are not inert and represent potential epileptogenic foci. Understanding the mechanisms of residual calcification in NCC is hindered by the difficulty of accessing human brain biopsies. Since cyst degeneration can be induced by antiparasitic treatment (APT) in NCC-infected pigs, this study assessed the residual calcification process in this model at three time points after APT.

METHODS/PRINCIPAL FINDINGS

Fifteen naturally infected pigs with viable NCC confirmed by magnetic resonance imaging received APT with albendazole and praziquantel and were sacrificed after 4, 8, and 12 months (n = 5 each). The pigs' brains were removed and processed by ex vivo CT scan to assess the proportion of cysts that calcified by post-treatment time points using risk ratios (RR) from Poisson regression. Radiodensity levels (Hounsefield units) of calcified lesions were also measured and compared using linear coefficients from log-transformed values in generalized linear models. The overall proportion of residual calcification on CT scan was 63.9% (156 calcified lesions/244 viable cysts), being statistically higher in treated NCC pigs at 4 months (83.3% [50/60], RR = 2.61, P < 0.001) and 8 months (82.8% [77/93], RR = 2.59, P < 0.001) versus 12 months (31.9% [29/91]). At 8 months after APT, calcifications were more dense (100.6 ± 3.6 HU) compared to 12 months (74.4 ± 3.6 HU, β = 0.37, P = 0.010) and marginally higher compared to 4 months (85.2 ± 3.8 HU, β = 0.24, P = 0.096), and were also larger and more frequently found on histopathology.

CONCLUSION/SIGNIFICANCE

Calcification in NCC is a dynamic process that can be induced and monitored in naturally infected pigs. Eight months after treatment seems to be an optimal time point for assessing residual calcification.

The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries

The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.

Management of calcified cysticerci in the brain parenchyma: treating the dead parasite

INTRODUCTION

Calcifications are the end stage of many parenchymal brain cysticerci and may occur either spontaneously or as the result of treatment with cysticidal drugs. These lesions, traditionally considered inert and asymptomatic, have been associated with several complications that seem to be mostly related to brain damage and inflammation ensuing as the result of the exposure of the host's immune system to parasitic antigens trapped within calcifications.

AREAS COVERED

This review, based on the search of different electronic databases up to May 2024, focuses on the reported correlates and complications of calcified cysticerci (chronic headaches, seizures/epilepsy, hippocampal atrophy/sclerosis, gliomas), and the different interventions developed for their prevention and treatment. Common analgesics, non-steroidal anti-inflammatory drugs, corticosteroids, and antiseizure medications have been used with success but, with the exception of the latter, these drugs offer temporary relief of symptoms and support for their use is based on level 3 evidence.

EXPERT OPINION

Several strategies may reduce the severity of clinical consequences of calcified cysticerci. Probably, the most relevant intervention would be the prevention of their occurrence or reduction in their size. In this view, the use of bisphosphonates appears as a potential option that needs to be tested in humans.

Transclival endoscopic approach for prepontine cistern neurocysticercosis causing trigeminal neuralgia: illustrative case

BACKGROUND

Neurocysticercosis (NCC) is a public health problem in most of the world. Approximately 50 million people worldwide experience this disease, and it remains one of the most important causes of neurological morbidity. Extraparenchymal NCC (basal cisterns) is associated with high rates of morbidity and mortality. Currently, minimally invasive approaches, including the endoscopic endonasal approach, are used with good functional results.

OBSERVATIONS

A 25-year-old patient presented with headache and pain in the left hemiface. Magnetic resonance imaging (MRI) showed cystic lesions in the prepontine basal cisterns compressing and displacing the left trigeminal nerve. The cysticercal lesions were excised using a transclival endoscopic approach. There were no complications during surgery, and pathology confirmed the diagnosis of NCC. The pain subsided after surgery. No residual cysts were observed on control MRI.

LESSONS

Minimally invasive approaches can be used to treat tumor and infectious problems of the skull base, as in this case, with good functional results. https://thejns.org/doi/10.3171/CASE24223.

Assessment of knowledge and practices regarding taeniasis and cysticercosis in Pak Chong, Nakhon Ratchasima, Thailand: A cross-sectional study

BACKGROUND

Taeniasis and cysticercosis are parasitic infections caused by Taenia spp., mainly transmitted through the consumption of undercooked pork. Prevention requires increasing knowledge and awareness, improving meat inspection and hygiene, and promoting safe food handling and sanitation. The aim of this study was to evaluate the knowledge and practice (KP) of residents in Pak Chong District, Nakhon Ratchasima, Thailand, regarding taeniasis and cysticercosis.

METHODS

A cross-sectional study was conducted in Pak Chong District, Nakhon Ratchasima, Thailand, and its 11 subdistrict municipalities. Study participants were selected using a stratified random sampling design. A validated questionnaire (Cronbach's alpha = 0.70) was used to collect socio-demographic information and assess knowledge and practices related to taeniasis and cysticercosis. Descriptive statistics and multiple linear regression were used for the analysis.

RESULTS

Of the 360 survey respondents, 65.0% (n = 234) were women, 82.2% (n = 296) were aged under 60 years, 99.2% (n = 357) identified as Buddhist, 87.5% (n = 315) had less than a bachelor's degree education level, 54.2% (n = 195) had monthly family income ≥10,000 Thai baht, 10.6% (n = 38) were unemployed, and 26.1% (n = 93) lived in a town municipality. The survey revealed that 98.3% (n = 354) of participants were categorized as having less accurate knowledge and 83.6% (n = 301) were classified as more frequently engaging in correct prevention practices. Our study revealed that pig farmers (1.7%) occasionally permitted the pigs to forage freely. The results of multiple linear regression analysis revealed that knowledge scores were positively associated with household income ≥10,000 Thai baht (βadj = 1.50, 95% confidence interval [CI] 0.65 to 2.36). Practice scores were negatively associated with age over 60 years (βadj = -1.77, 95% CI -3.14 to -0.40) and living in a subdistrict municipality (βadj = -2.58, 95% CI -3.77 to -1.39). There was no association between KP regarding taeniasis and cysticercosis in the population of Pak Chong.

CONCLUSIONS

Overall, participants' knowledge was lacking. Public education interventions are recommended to improve knowledge among residents with low socioeconomic status. These findings can inform the development of targeted interventions and educational programs in Pak Chong District, especially among elderly people in subdistrict municipalities, to improve practices for the prevention and control of these parasitic infections.

Concordance between two monoclonal antibody-based antigen detection enzyme-linked immunosorbent assays for measuring cysticercal antigen levels in sera from pigs experimentally infected with Taenia solium and Taenia hydatigena

BACKGROUND

Antigen detection in Taenia solium cysticercosis confirms viable infection in the intermediate host (either pig or human). The reference B158/B60 monoclonal antibody (mAb)-based Ag-enzyme-linked immunosorbent assay (ELISA) has acceptable levels of sensitivity and specificity in human neurocysticercosis with multiple brain cysts, although its sensitivity is lower in cases with single brain cysts, whereas in porcine cysticercosis the assay specificity is affected by its frequent cross-reaction with Taenia hydatigena, another common cestode found in pigs. Our group has produced 21 anti-T. solium mAbs reacting against antigens of the whole cyst, vesicular fluid, and secretory/excretory products, identifying TsW8/TsW5 as the most promising pair of mAbs for an Ag-ELISA.

METHODS

We report the use of the TsW8/TsW5 Ag-ELISA to measure cysticercus antigen levels [expressed as optical density (OD) values] in two panels of sera collected from day 0 (baseline) to day 90 postinfection (PI) from pigs experimentally infected with T. solium (n = 26) and T. hydatigena (n = 12). At baseline and on days 28 and 90 PI, we used Bland-Altman (BA) analysis and Lin's concordance correlation coefficients (CCC) to determine the concordance between the TsW8/TsW5 and the B158/B60 Ag-ELISA.

RESULTS

The TsW8/TsW5 Ag-ELISA was able to efficiently measure circulating antigen levels in T. solium-infected pigs, similar to that obtained with the B158/B60 Ag-ELISA. Almost all paired log-OD differences between assays were within the limits of agreement (LoA) in the BA analysis at baseline and on days 28 and 90 PI (92.3%, 100%, and 100%, respectively), and a high concordance of log-ODs between assays was also found (Lin's CCC: 0.69, 0.92, and 0.96, respectively, all P < 0.001). In pigs infected with T. hydatigena, almost all paired log-OD differences were within the LoA in the BA analysis, whereas the concordance of log-ODs between assays was low at baseline (Lin's CCC: 0.24) but increased on days 28 and 90 PI (Lins' CCC: 0.88 and 0.98, P < 0.001).

CONCLUSIONS/SIGNIFICANCE

The TsW8/TsW5 Ag-ELISA recognizes antigens in pigs with T. solium cysticercosis and is highly concordant with the B158/B60 Ag-ELISA. However, its diagnostic use is hampered by cross-reactions with T. hydatigena, as in other mAb-based Ag-ELISAs.

Epilepsy and neurocysticercosis in rural areas of the Bolivian Chaco: What has changed during the last 30 years?

OBJECTIVE

Neurocysticercosis (NCC) is considered the major cause of epilepsy in endemic regions. In the rural areas of the Bolivian Chaco prevalence of NCC among people with epilepsy (PWE) was 27.4%, according to a population-based survey carried out in 1994. The aim of the study was to estimate the prevalence of Epilepsy Associated with Tonic-Clonic Seizures (EATCS) and to evaluate the prevalence of NCC among PWE in the rural communities of the Bolivian Chaco after 30 years.

METHODS

Twenty-two rural communities (total population 12 852) were involved in the study. PWE in the study area were ascertained by multiple sources and the diagnosis was confirmed by a neurologist. All PWE identified were invited to undergo brain CT scan examination and diagnosis of NCC was sought according to the revised Del Brutto criteria.

RESULTS

Seventy-eight PWE (30 men, 38.4%; mean age at onset was 12.7 ± 13.2 years) with EATCS were identified giving a crude prevalence of 6.1/1000 (95% CI: 4.7-7.3). Due to the COVID-19 lockdown, the study was interrupted in 2020 and only 36 PWE (46%) of the whole sample underwent CT scan examination. Of these, 8 (22.2%) fulfilled the criteria for NCC of whom 6 (75%) presented only single or multiple calcifications.

SIGNIFICANCE

This is the first study reassessing the prevalence of NCC among PWE after 30 years, in the same rural area and using a population-based design. T. solium is still endemic in the Bolivian Chaco where more than 20% of EATCS may be attributable to NCC. Our findings show a substantially unchanged prevalence of NCC over the past 30 years despite improved knowledge, underlining the need for active intervention programs to control T. solium transmission in this area.

PLAIN LANGUAGE SUMMARY

Neurocysticercosis is still endemic in the Bolivian Chaco. The proportion of epilepsy attributable to neurocysticercosis is about 22%. Systematic efforts towards elimination of neurocysticercosis in these areas should be implemented.

Current Role of Surgery in the Treatment of Neurocysticercosis

Neurocysticercosis (NCC) is a common parasitic disease of the central nervous system (CNS) in low- and middle-income countries. The infection is pleomorphic, caused by the larval form of the cestode, Taenia solium, and part of the heterogeneity of its clinical presentations is associated with the localization of the parasite within the CNS. Changes in the current epidemiological trends of NCC indicate that extra-parenchymal NCC is proportionally becoming more frequent. Extraparenchymal NCC is commonly accompanied by raised intracranial hypertension due to hydrocephalus, which is an emergency requiring cyst extirpation by surgical intervention to relieve the symptoms. Although less frequent, parenchymal cysts may also reach giant sizes requiring urgent surgical treatment. Finally, there is an advancement in the comprehension of the association between NCC and epilepsy-and patients with drug-resistant seizures are candidates for surgical treatment. In this narrative review, we summarize the present state of knowledge to update the current trends in the role of surgery in the treatment of NCC.

Taenia solium Cysticercosis and Taeniosis Reporting in the Current Medical and Veterinary Diseases Reporting Systems in Tanzania: A Cross-Sectional Study

Taenia solium cysticercosis and taeniosis (TSCT) are two forms of a zoonotic disease caused by T. solium tapeworm. Towards promotion of a One Health approach to the control of TSCT, we assessed TSCT reporting in the medical and veterinay sectors in Tanzania. We conducted a cross-sectional study between January and April 2020 in Babati and Mbulu districts (northern Tanzania), Kongwa district (central Tanzania), Mbinga and Nyasa districts (southern Tanzania), and the Zonal Veterinary Centres in Iringa (southern Tanzania) and Arusha (northern Tanzania) regions. A questionnaire was administered to 154 officers in charge (OsIC) of primary healthcare facilities (PHFs) and 110 meat inspectors (MIs) to collect quantitative data. Key informant interviews (KIIs) were conducted to 16 medical and 17 veterinary officers from level one healthcare facilities and district livestock offices, respectively, to their respective ministries. OsIC admitted absence of specific reporting (100%, n = 154) of T. solium taeniosis and neurocysticercosis (NCC) in the medical diseases reporting system (MDRS) despite the presence of optimum facilitation in terms of report preparation and submission (92.2%, n = 154) with 83.8% (n = 154) timely report submission rate. The veterinary diseases reporting system (VDRS) accommodated porcine cysticercosis (PCC) reporting. Nevertheless, approximately 77.3% (n = 110) of the MIs admitted inadequate facilitation in VDRS that hindered efficient reporting of PCC among other diseases. In addition, all MIs admitted that disease reports submitted were incomplete, submitted late (73.3%, n = 110), or not submitted at all (88.8%, n = 110). Similarly, KIIs results revealed suboptimal facilitation and reporting efficiency in VDRS than it was with the MDRS. It is concluded that the MDRS did not provide for specific reporting of taeniosis and NCC. Inadequate facilitation of the general VDRS hindered efficient PCC reporting despite its provision for PCC reporting. A One Health approach in strengthening the medical and veterinary diseases reporting systems for efficient TSCT reporting is recommended.

[Diagnosis of neurocysticercosis in patients with epilepsy living in the south-western Dominican Republic]

INTRODUCTION

Neurocysticercosis (NCC), a possible cause of epilepsy with limited epidemiological data in the Dominican Republic, is endemic in four provinces in the country's south-western region. This study aimed to determine the association between NCC and epilepsy among people living in these endemic regions, and to obtain preliminary data on the prevalence of NCC in these provinces.

PATIENTS AND METHODS

A case-control design was used, consisting of 111 patients with epilepsy with unknown causes, and 60 controls without epilepsy or NCC. The diagnosis of NCC was based on computed tomography and magnetic resonance imaging of the skull, as well as Western immunoblotting for serum antibodies using Taenia solium, following the criteria of Del Brutto et al. RESULTS. NCC was found in 27% of the epileptic patients (n = 30/111) and in 5% of the controls (n = 3/60); the probability of the epileptic patients having NCC was seven times higher than the controls (odds ratio = 7.04, 95% confidence interval: 2.04-24.18; p < 0.001). The participants' sociodemographic characteristics, including their age, sex, level of education, occupation, and province of residence presented no statistical significance in terms of their association with NCC.

CONCLUSIONS

This study suggests that NCC is strongly associated with epilepsy in the south-western region of the Dominican Republic, and highlights the need for public health measures to improve the prevention, diagnosis and treatment of both diseases.

Is Antihelminthics Necessary in Postoperative Treatment of Intraventricular Neurocysticercosis? A Systematic Review

OBJECTIVE

Patients with intraventricular neurocysticercosis (IVNCC) may require cerebrospinal fluid diversion surgery for late-onset hydrocephalus in the postsurgical period. Controversy exists regarding cysticidal treatment. Our main objective was to compare surgically treated cases of IVNCC that received postoperative anthelmintics with those that did not regard the incidence and treatment of late-onset hydrocephalus.

METHODS

We searched the Medline database and extracted the following data: age, gender, stage of development of cysticercosis, type of operation, frequency of delayed hydrocephalus, cerebrospinal fluid diversion surgery, outcome, and follow-up.

RESULTS

We analyzed 130 articles on intraventricular cysticercosis and identified 117 cases of isolated IVNCC and 314 patients in the case-control series who met inclusion criteria. There was no significant difference in postoperative delayed hydrocephalus between isolated IVNCC and case-control study groups. Children under the age of 16 received anthelmintic drugs more frequently during the postoperative period. Statistical relevance was observed in all patient groups regarding the application of steroids in favor of cysticidal therapy Endoscopy was a better option than craniotomy for cases of isolated IVNCC and case-control studies. Other variables were not relevant.

CONCLUSIONS

Patients who received antihelminths did not show a statistically significant reduction in delayed hydrocephalus compared to individuals who did not receive after surgical resection of the parasite. Corticosteroid therapy prevailed in people who have been treated with anthelmintics. Children under the age of 16 were administered anthelmintic drugs more frequently during the postoperative period. Endoscopy was the preferred method for all groups, but some patients with cysts in the fourth ventricle required a craniotomy.

[A multicentre epilepsy registry in Mexico]

INTRODUCTION

The National Epilepsy Registry in Mexico was carried out, from March 2021 to December 2022, in public hospitals of the Priority Epilepsy Program 'PPE', with the aim of describing the current situation in our pediatric and adult population.

PATIENTS AND METHODS

Observational, cross-sectional, multicenter study. We used a database, according to classifications of the International League Against Epilepsy (ILAE) 2017. Patients of all ages were included, with a diagnosis of epilepsy according to the practical clinical definition ILAE 2014.

RESULTS

We registered 10,852 patients, 5,495 men (50.6%) and 5,357 women (49.4%). Family history of epilepsy in 1,714 patients (15.8%), febrile seizures in 987 (9.1%). Type of seizure: 5,542 (51.1%) presented focal onset, of which 1,889 (34.1%) evolved to bilateral tonic-clonic seizures; generalized onset 4,861 (44.8%), unknown 33 (3.1%) and unclassified 115 (1.1%). Almost half had unknown etiology and 40% were structural, of which hypoxic ischemic encephalopathy was the most frequent (21.6%) and neurocysticercosis was 1%. Comorbidities appeared in 6,326 patients (58.3%). Anti-seizure medications (ASM) were used in 96.4% patients, mainly valproate. Status epilepticus was found in 1,383 patients (12.7%) and drug-resistant epilepsy in 18.9%. Paraclinical studies: 79.3% with at least one electroencephalogram and 76.9% with a neuroimaging study. Epilepsy surgery occurred in 275 patients (2.5%).

CONCLUSIONS

Despite the efforts of the Pan American Health Organization in its Strategy and Action Plan on epilepsy, diagnostic technologies and ASM supply are still lagging behind.

Calcified Neurocysticercosis: Demographic, Clinical, and Radiological Characteristics of a Large Hospital-Based Patient Cohort

Neurocysticercosis (NCC), the infection of the central nervous system caused by Taenia solium larvae (cysticerci), is a major cause of acquired epilepsy worldwide. Calcification in NCC is the most common neuroimaging finding among individuals with epilepsy in T. solium-endemic areas. We describe the demographic, clinical, and radiological profiles of a large hospital cohort of patients with calcified NCC in Peru (during the period 2012-2022) and compared profiles between patients with and without a previous known diagnosis of viable infection. A total of 524 patients were enrolled (mean age at enrollment: 40.2 ± 15.2 years, mean age at symptom onset: 29.1 ± 16.1 years, 56.3% women). Of those, 415 patients (79.2%) had previous seizures (median time with seizures: 5 years, interquartile range (IQR): 2-13 years; median number of seizures: 7 (IQR: 3-32)), of which 333 (80.2%) had predominantly focal to bilateral tonic-clonic seizures; and 358 (68.3%) used antiseizure medication). Patients had a median number of three calcifications (IQR: 1-7), mostly located in the frontal lobes (79%). In 282 patients (53.8%) there was a previous diagnosis of viable infection, while 242 only had evidence of calcified NCC since their initial neuroimaging. Most patients previously diagnosed with viable infection were male, had previous seizures, had seizures for a longer time, had more calcifications, and had a history of taeniasis more frequently than patients without previously diagnosed viable infection (all p < 0.05). Patients with calcified NCC were heterogeneous regarding burden of infection and clinical manifestations, and individuals who were diagnosed after parasites calcified presented with milder disease manifestations.

Multiantigen print immunoassay (MAPIA) for the diagnosis of neurocysticercosis: a single-center diagnostic optimization and accuracy study in Lima, Peru

Neurocysticercosis (NCC) is the most common helminthic infection of the human central nervous system. The antibody detection assay of choice is the enzyme-linked immunoelectrotransfer blot assay using lentil-lectin purified parasite antigens (LLGP-EITB, Western blot), an immunoassay with exceptional performance in clinical samples. However, its use is mainly restricted to a few research laboratories because the assay is labor-intensive and requires sophisticated equipment, expertise, and large amounts of parasite material for preparation of reagents. We report a new immunoprint assay (MAPIA) that overcomes most of these barriers. We initially compared the performance of five different antigen combinations in a subset of defined samples in the MAPIA format. After selecting the best-performing assay format (a combination of rGP50 + rT24H + sTs14 antigens), 148 archived serum samples were tested, including 40 from individuals with parenchymal NCC, 40 with subarachnoid NCC, and 68 healthy controls with no evidence of neurologic disease. MAPIA using three antigens (rGP50 + rT24H + sTs14) was highly sensitive and specific for detecting antibodies in NCC. It detected 39 out of 40 (97.5%) parenchymal NCC cases and 40/40 (100%) subarachnoid cases and was negative in 67 out of 68 (98.53%) negative samples. MAPIA using three recombinant and synthetic antigens is a simple and economical tool with a performance equivalent to the LLGP-EITB assay for the detection of specific antibodies to NCC. The MAPIA overcomes existing barriers to adoption of the EITG LLGP and is a candidate for worldwide use.

Clinical Characteristics of Neurocysticercosis in a Peruvian Population-Based Epilepsy Cohort: A Descriptive Cross-Sectional Study of Baseline Clinical Intake

(1) Background: This study presents the baseline characteristics of a community-level population of people with epilepsy (n = 1975) living in an area endemic for Taenia solium, the pathogen responsible for neurocysticercosis (NCC). (2) Methods: Participants were sequentially enrolled in a clinical cohort from 2007 to 2020 in Tumbes, Peru. All participants provided demographic and clinical history and received clinical evaluations. Diagnostics, including neuroimaging, cysticercosis serologies, and EEG, were obtained where possible. The data presented are from the cross-sectional baseline assessment of cohort participants. (3) Results: Approximately 38% of participants met the criteria for NCC. Those with NCC were more likely to have adult-onset epilepsy, as well as a longer duration of epilepsy, as compared to their counterparts without NCC. Overall, the data indicate a large treatment gap, with only approximately a quarter of the baseline population with prescriptions for anti-seizure medications. (4) Conclusions: These data reveal a high proportion of NCC among people living with epilepsy in these communities, with limited health care resources. At baseline, 74% of the population were not receiving anti-seizure treatments. Further analyses of these data will clarify the natural history of the disease for this population.

Serological and molecular detection of neurocysticercosis among epileptic patients in Nagpur, Maharashtra state (India)

Neurocysticercosis (NCC), one of the most important neuroparasitic diseases in humans, is caused by Cysticercus cellulosae, the metacestode stage of digenetic zoonotic cestode Taenia solium. The present study aims at the detection of anti-cysticercus antibodies in the sera of epileptic patients (n=26) visiting a tertiary care hospital in Nagpur, Maharashtra state, India, by an in-house developed indirect IgG-ELISA and enzyme-linked immunoelectro transfer blot (EITB) assay using different antigens (namely, Whole Cyst Antigen (WCA), Cystic Fluid Antigen (CFA), Scolex Antigen (SA), Excretory-Secretory Antigen (ESA) and Membrane-Body Antigen (MBA)) prepared from T. solium metacestodes to find out the status of NCC. An attempt has also been made for molecular detection of NCC from blood samples of those patients by Polymerase Chain Reaction (PCR) assay targeted at large subunit rRNA gene of T. solium. The IgG ELISA level of anti-cysticercus antibodies against WCA, CFA, SA, ESA and MBA antigens were as follows: 19.23 %, 23.07 %, 38.46 %, 30.76 % and 15.38 %. The seroreactivity to CFA, SA and ESA was found in equal proportions in patients with ring-enhancing lesions. In the EITB assay, the lower and medium molecular weight protein bands of SA and ESA were immunodominant compared to the higher WCA and CFA peptides. PCR positivity could be observed in 34.6 % (9/26) of the patients under study. It is the first report of detecting NCC among epileptic patients of the Nagpur region of Maharashtra state in India using serological and molecular tools.

Consistent Measurement of Parasite-Specific Antigen Levels in Sera of Patients with Neurocysticercosis Using Two Different Monoclonal Antibody (mAb)-Based Enzyme-Linked Immunosorbent Assays

Monoclonal antibody (mAb)-based enzyme-linked immunosorbent assay (ELISA) is a complementary diagnosis technique for neurocysticercosis (NCC), which detects circulating parasite antigen (Ag) indicative of viable infection and Ag levels that correlate well with the parasite burden. In this study, we compared the performance of two Ag-ELISA techniques for the detection of NCC. We assessed the agreement between our in-house TsW8/TsW5 Ag-ELISA and the widely used B158/B60 Ag-ELISA for measuring T. solium antigen levels in the sera from 113 patients with calcified, parenchymal, and subarachnoid NCC. Concordance was demonstrated evaluating the limits of agreement (LoAs) stratified by the type of NCC. Both ELISA's detected 47/48 (97.8%) subarachnoid NCC cases. In parenchymal and calcified NCC, the B158/B60 Ag-ELISA detected 19/24 (79.2%) and 18/41 (43.9%) cases, while the TsW8/TsW5 Ag-ELISA detected 21/24 (87.5%) and 13/41 (31.7%), respectively. Parenchymal and calcified NCC obtained a perfect agreement (100%), indicating that all sample results were within the predicted LoA, while for subarachnoid NCC, the agreement was 89.6%. The high concordance between the assays was confirmed by Lin's concordance coefficient (LCC = 0.97). Patients with viable parenchymal NCC (LCC = 0.95) obtained the highest concordance between assays, followed by subarachnoid NCC (LCC = 0.93) and calcified NCC (LCC = 0.92). The TsW8/TsW5 Ag-ELISA and B158/B60 Ag-ELISA showed high Ag measurement correlations across diverse types of NCC.

Prevalence of epilepsy in the rural area of the Bolivian Gran Chaco: Usefulness of telemedicine and impact of awareness campaigns

OBJECTIVE

The objective of this study is to estimate the prevalence of epilepsy with Tonic-Clonic (TC) seizures in rural areas of the Bolivian Gran Chaco and to evaluate the usefulness of telemedicine in this context.

METHODS

The study was carried out in the Isozo Area, southern-eastern Bolivia. Twenty-five rural communities with a population of 8258 inhabitants were included in the survey. Trained community-health workers administered a validated single screening question to the householders (stage I). A second face-to-face questionnaire was administered to each positive subject (stage II). At stage II subjects were also screened using the smartphone app "Epilepsy Diagnosis Aid". Subjects screened positive at stage II underwent a complete neurological examination to confirm the diagnosis (stage III). Due to the COVID-19 lockdown, some subjects have been evaluated through a digital platform (Zoom®).

RESULTS

One-thousand two-hundred and thirteen interviews were performed at stage I, corresponding to a total screened population of 6692 inhabitants. Thirty-eight screened positive were identified at stage I and II and of these, 28 people with epilepsy were identified, giving an overall prevalence of 4.2/1000 (95% CI 2.6-5.7). Prevalence rate steeply increased with age reaching a peak of 7.9/1000 in the population aged 20-29 years without significant differences between women and men. For almost 50% of the screened positive subjects, confirmation of epilepsy by a neurologist at stage III was achieved through simple videoconsultation. After a simultaneous awareness campaign, 22 self-reported PWE requested a consultation and, among them, 11 had a diagnosis of epilepsy confirmed.

SIGNIFICANCE

This study shows a prevalence estimate close to those reported for LMIC. Simple videoconsultation and specific apps may be valuable tools in epidemiological research. Awareness campaigns are important allies for a full case identification, particularly in contexts where higher rates of stigma are recorded.

Status of epilepsy in the tropics: An overlooked perspective

Epilepsy is one of the most common serious chronic neurological diseases affecting people of all ages globally. It is characterized by recurrent seizures. About 50 million people worldwide have epilepsy. Indubitably, people with epilepsy (PWE) may be without access to appropriate treatment. Many studies have examined the molecular mechanisms and clinical aspects of epilepsy; nonetheless, the treatment gap exists in some special areas. In the tropics, the specific geographical and ecological conditions and a lack of medical resources result in neglect or delay of diagnosis for PWE. Herein, we summarized the epidemiology of epilepsy in the tropics and discussed the disease burden and existing problems, aiming to offer a medical environment for patients in need and highlight the importance of reducing the epileptic disease burden in tropical countries.

Taenia solium taeniasis/cysticercosis in Guatemala: a prevalent public health problem?

In Guatemala, neurocysticercosis (NCC) was first recognized in 1940; since then, cases of NCC have been reported in all Guatemalan departments. However, epidemiological studies on Taenia solium infections are scarce and most information remains unpublished. This study aims to provide evidence of T. solium infections as a public health problem in Guatemala. All information available, either published or unpublished, on T. solium infections in the country was compiled. Official data from the Ministry of Health for the period 2003-2019 were reviewed and analyzed, and all cases of T. solium infections were classified and counted. In total, 5246 cases of taeniasis and 454 cases of human cysticercosis were recorded. On the other hand, 44 studies were identified, mostly from local journals, which included 1951 cases of taeniasis, 2873 cases of human cysticercosis of which 543 were classified with complete diagnosis, and 2590 cases of porcine cysticercosis. Cases were classified by geographic region, patient sex, and Taenia species in taeniasis cases when information was available, and the departments with the highest number of taeniasis and cysticercosis cases were identified. Meanwhile, in Zacapa, a northeastern department of Guatemala with one the highest number of taeniasis cases, a young man diagnosed with a severe form of NCC and two cases of porcine cysticercosis (both confirmed by necropsy) were identified. Taken together, the data herein reported indicate that T. solium infections are a major health problem in Guatemala that needs to be addressed.

Transventricular endoscopic approach to the anterior interhemispheric fissure for neurocysticercosis: illustrative cases

BACKGROUND

Neurocysticercosis (NCC) is a global public health problem. It is a complex disease to manage and a cause of great morbidity and mortality in affected patients. Conventional surgical approaches have been used for many years, but currently, minimally invasive approaches are being used with good results. The authors present a case of NCC in the anterior interhemispheric fissure that was treated with a transventricular endoscopic approach.

OBSERVATIONS

A 32-year-old male patient was admitted for persistent moderate headache and dizziness. Gadolinium-enhanced magnetic resonance imaging (MRI) showed multiple parenchymal, ventricular, and subarachnoid cystic lesions, especially in the anterior interhemispheric space. A transventricular endoscopic approach was selected and applied. There were no complications during surgery. Pathological analysis confirmed the diagnosis of NCC. Control MRI demonstrated the absence of cysts in the anterior interhemispheric space.

LESSONS

Minimally invasive approaches are an excellent alternative for patients with NCC, especially if a patient requires more than one surgery.

Long-Standing International Cooperation in Parasitology Research: A Summary of 35 Years of Activities in the Bolivian Chaco

The Bolivian Chaco is a semiarid region with a low population density, situated in the southeast part of the Plurinational State of Bolivia. Here, despite the improvements of the last 15 years, poverty remains high in rural areas, where social vulnerability is widespread. The Guaraní ethnic group often lives in isolated communities with a low standard of hygiene and sanitation. This epidemiological scenario favors the spread of transmissible diseases, including several parasitic infections belonging to the neglected tropical diseases (NTDs) group. In this area, a long-standing research activity, built upon the synergism between local and foreign institutions, has been established since the late 1980s and helps to fill in the knowledge gap about the epidemiology dynamics of soil-transmitted helminths, vector-borne parasites, and other parasitic diseases. A 35-year history of cooperation programs in parasitology research has contributed to informing local health authorities of the NTD burden in the Bolivian Chaco and, ultimately, supports local healthcare providers in the management of parasitic diseases.

Experimental brain infection with cysticercosis in sheep

OBJECTIVE.

To explore the feasibility of developing a sheep model of neurocysticercosis (NCC) by intracranial infection with T. solium oncospheres.

MATERIALS AND METHODS.

We carried out an experimental infection model of NCC in sheep. Approximately 10 T. solium oncospheres previously cultured for 30 days were inoculated intracranially into ten sheep. The oncospheres, in 0.1 mL of physiological saline, were injected into the parietal lobe through an 18-gauge needle.

RESULTS.

After three months, granulomas were found in two sheep. In a third sheep we identified a 5 mm diameter cyst in the right lateral ventricle and histological evaluation confirmed that the cyst corresponded to a T. solium larva. Immunohistochemistry with monoclonal antibodies directed against membrane components and excretory/secretory antigens of the T. solium cyst was also used to confirm the etiology of the found granulomas. One of them showed reactivity to the monoclonal antibodies used, thus confirming that it was a cysticercus.

CONCLUSION.

This experiment is the proof of concept that it is possible to infect sheep with cysticercosis by intracranial inoculation.

Challenges in the Diagnosis of Taenia solium Cysticercosis and Taeniosis in Medical and Veterinary Settings in Selected Regions of Tanzania: A Cross-Sectional Study

Background

Taenia solium (neuro) cysticercosis/taeniosis (TSCT) is a zoonotic disease complex. There is a perceived inefficient diagnosis of infections by either form, the adult pork tapeworm (taeniosis) and the larval stage of it (cysticercosis), in low-income settings, including Tanzania. This study aimed at identifying potential gaps around TSCT diagnosis and knowledge of primary healthcare providers (officers in charge (OICs) of primary healthcare facilities (PHFs)) and veterinarians (meat inspectors (MIs)) on various aspects of TSCT disease complex and addressing effective disease control in Tanzania. Methodology. A cross-sectional study was conducted between January and April 2020 in Manyara, Dodoma, Ruvuma, Iringa, and Arusha regions in Babati, Mbulu, Kongwa, Mbinga, and Nyasa districts. We interviewed 152 OICs of PHFs and 108 MIs using a structured questionnaire and 33 medical and veterinary officers from level I healthcare facilities and district livestock offices, respectively, from selected study districts to the respective ministerial level using key informant interviews.

Results

Quantitative data revealed inadequate microscopic diagnostic facilities (54.6%) and personnel (100%) for taeniosis diagnosis in PHFs (n = 152). Approximately 81.2% of MIs compared with only 42.1% of OICs of PHFs scored above average regarding T. solium cysticerci knowledge. Nevertheless, 61.2% of OICs of PHFs compared with only 42.6% of MIs scored above average regarding the adult T. solium tapeworm knowledge. Qualitative data revealed inadequate availability of advanced diagnostic facilities (neuroimaging) and trained personnel for specific diagnosis of TSCT with a focus on neurocysticercosis (NCC) in secondary and tertiary healthcare facilities. Inadequately number of qualified MIs, slaughter slabs, and resource facilitation challenged porcine cysticercosis diagnosis.

Conclusion

It is concluded that diagnostic capacity and knowledge of OICs of PHFs and MIs regarding TSCT are insufficient in both medical and veterinary sectors. A One Health approach should be adopted to improve TSCT diagnostic capacity and practitioners' knowledge in both medical and veterinary sectors.

CystiHuman: A model of human neurocysticercosis

INTRODUCTION

The Taenia solium tapeworm is responsible for cysticercosis, a neglected tropical disease presenting as larvae in the body of a host following taenia egg ingestion. Neurocysticercosis (NCC), the name of the disease when it affects the human central nervous system, is a major cause of epilepsy in developing countries, and can also cause intracranial hypertension, hydrocephalus and death. Simulation models can help identify the most cost-effective interventions before their implementation. Modelling NCC should enable the comparison of a broad range of interventions, from treatment of human taeniasis (presence of an adult taenia worm in the human intestine) to NCC mitigation. It also allows a focus on the actual impact of the disease, rather than using proxies as is the case for other models.

METHODS

This agent-based model is the first model that simulates human NCC and associated pathologies. It uses the output of another model, CystiAgent, which simulates the evolution of pig cysticercosis and human taeniasis, adding human and cyst agents, including a model of cyst location and stage, human symptoms, and treatment. CystiHuman also accounts for delays in the appearance of NCC-related symptoms. It comprises three modules detailing cyst development, seizure probability and timing, and intracranial hypertension/hydrocephalus, respectively. It has been implemented in Java MASON and calibrated in three endemic villages in Peru, then applied to another village (Rica Playa) to compare simulation results with field data in that village.

RESULTS AND DISCUSSION

Despite limitations in available field data, parameter values found through calibration are plausible and simulated outcomes in Rica Playa are close to actual values for NCC prevalence and the way it increases with age and cases with single lesions. Initial simulations further suggest that short-term interventions followed by a rapid increase in taeniasis prevalence back to original levels may have limited impacts on NCC prevalence.

Incidence of Adult-Onset Epilepsy and the Contributory Role of Neurocysticercosis in a Five-Year, Population-Based, Prospective Study in Rural Ecuador

This prospective cohort study aimed to assess incidence and etiology of adult-onset epilepsy in previously seizure-free Atahualpa residents aged ≥ 20 years. Persons with adult-onset epilepsy occurring over 5 years were identified from annual door-to-door surveys and other overlapping sources. Those who emigrated or declined consent were excluded at the administrative censoring date of the last survey when these subjects were interviewed. Persons who died and those who developed incident epilepsy were censored at the time of these outcomes. Poisson regression models adjusted for demographics, education, alcohol intake, and the length of observation time, were used to estimate annual adult-onset epilepsy incidence rate ratio and cumulative incidence. Systematic neuroimaging screening was offered to participants to get insights on the etiology of epilepsy. Individuals enrolled in this cohort (N = 1,480) contributed to 6,811.6 years of follow-up. Seventeen developed incident adult-onset epilepsy, for an annual incident rate of 249.2 per 100,000 persons-year (95% CI: 130.7-367.7). Cumulative incidence was 1,245.9 per 100,000 persons (95% CI: 653.7-1,838.3) after a mean of 4.6 (SE: 0.06) years of follow-up. Six persons with incident epilepsy had neurocysticercosis (35%). Individuals with neurocysticercosis were six times more likely to develop adult-onset epilepsy than those without this disease (IRR: 6.01; 95% CI: 2.16-16.7), after adjusting for relevant covariates. The attributable fraction of incident adult-onset epilepsy due to neurocysticercosis was 30.9% (95% CI: 25.6-46.2%). This rural Ecuadorian population has a high incidence of adult-onset epilepsy, with neurocysticercosis being an important contributory cause.

Burden of epilepsy in Latin America and The Caribbean: a trend analysis of the Global Burden of Disease Study 1990 - 2019

Background

The epilepsy prevalence in Latin America and the Caribbean (LAC) had remained high over the last 20 years. Data on the burden of epilepsy are needed for healthcare planning and resource allocation. However, no systematic analysis had been performed for epilepsy burden in LAC.

Methods

We extracted data of all LAC countries from the Global Burden of Disease (GBD) study from 1990 to 2019. Epilepsy burden was measured as prevalence, mortality, and disability-adjusted life-years (DALYs; defined by the sum of years of life lost [YLLs] for premature mortality and years lived with disability [YLDs]), by age, sex, year, and country. Absolute numbers, rates, and 95% uncertainty intervals were reported. We performed correlational analyses among burden metrics and Socio-demographic Index (SDI).

Findings

The burden of epilepsy decreased around 20% in LAC, led by YLLs reduction. In 2019, 6·3 million people were living with active epilepsy of all causes (95% UI 5·3 - 7·4), with 3·22 million (95% UI 2·21 - 4·03) and 3·11 million (95% UI 2·21 to 4·03) cases of epilepsy with identifiable aetiology and idiopathic epilepsy, respectively. The number of DALYs represented the 9·51% (1.37 million, 95% UI 0·99 -1·86) of the global epilepsy burden in 2019. The age-standardized burden was 175·9 per 100 000 population (95% UI 119·4 - 253·3), which tend to have a bimodal age distribution (higher in the youth and elderly) and was driven by high YLDs estimates. The burden was higher in men and older adults, primarily due to high YLLs and mortality. Alcohol use was associated with 17% of the reported DALYs. The SDI estimates significantly influenced this burden (countries with high SDI have less epilepsy burden and mortality, but not prevalence or disability).

Interpretation

The epilepsy burden has decreased in LAC over the past 30 years. Even though, LAC is still ranked as the third region with the highest global epilepsy burden. This reduction was higher in children, but burden and mortality increased for older adults. The epilepsy burden is disability predominant; however, the mortality-related estimates are still higher than in other regions. Alcohol consumption and countries' development are important determinants of this burden. There is an urgent need to improve access to epilepsy care in LAC, particularly for older adults. Strengthening primary care with online learning and telemedicine tools, and promoting risk factors modification should be prioritized in the region.

Funding

This research was self-funded by the authors.

Spatial distribution and risk factors for human cysticercosis in Colombia

Background

Cysticercosis is a zoonotic neglected tropical disease (NTD) that affects humans and pigs following the ingestion of Taenia solium eggs. Human cysticercosis poses a substantial public health burden in endemic countries. The World Health Organization (WHO) aims to target high-endemicity settings with enhanced interventions in 17 countries by 2030. Between 2008 and 2010, Colombia undertook a national baseline serosurvey of unprecedented scale, which led to an estimated seroprevalence of T. solium cysticercus antibodies among the general population of 8.6%. Here, we use contemporary geostatistical approaches to analyse this unique dataset with the aim of understanding the spatial distribution and risk factors associated with human cysticercosis in Colombia to inform how best to target intervention strategies.

Methods

We used a geostatistical model to estimate individual and household risk factors associated with seropositivity to T. solium cysticercus antibodies from 29,253 people from 133 municipalities in Colombia. We used both independent and spatially structured random effects at neighbourhood/village and municipality levels to account for potential clustering of exposure to T. solium. We present estimates of the distribution and residual correlation of seropositivity at the municipality level.

Results

High seroprevalence was identified in municipalities located in the north and south of Colombia, with spatial correlation in seropositivity estimated up to approximately 140 km. Statistically significant risk factors associated with seropositivity to T. solium cysticercus were related to age, sex, educational level, socioeconomic status, use of rainwater, consumption of partially cooked/raw pork meat and possession of dogs.

Conclusions

In Colombia, the distribution of human cysticercosis is influenced by socioeconomic considerations, education and environmental factors related to the spread of T. solium eggs. This information can be used to tailor national intervention strategies, such as targeting spatial hotspots and more highly exposed groups, including displaced people and women. Large-scale seroprevalence surveys accompanied by geospatial mapping are an essential step towards reaching the WHO’s 2021‒2030 NTD roadmap targets.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-05092-8.

Endoscopic endonasal surgery for massive subarachnoid neurocysticercosis: illustrative case

BACKGROUND

Subarachnoid neurocysticercosis (NCC) is associated with high morbidity and mortality rates. Conventional transcranial approaches and transventricular endoscopy have been previously reported for extraparenchymal NCC and ventricular NCC, respectively. By October 2019, endonasal endoscopic approaches had not been used for the treatment of NCC.

OBSERVATIONS

A 54-year-old-woman with NCC was admitted with acute neurological deterioration due to severe intracranial hypertension caused by massive subarachnoid NCC cysts, as evidenced on magnetic resonance imaging (MRI) with great brainstem compression. The case was discussed, and an endoscopic endonasal resection of the NCC cysts was scheduled. The diagnosis was confirmed by pathological anatomy. There were no complications in the surgery, with marked neurological improvement. Control MRIs demonstrated a significant reduction of NCC cysts.

LESSONS

Minimally invasive approaches are an excellent alternative for skull-base tumoral and infectious pathology. Prior knowledge of the pathophysiology and the authors’ experience in the management of patients with NCC allowed them to propose this approach, with optimal results.

Seroprevalence of Cysticercosis among Epileptic Patients Attending Neurological Units in the Urban Area of Abidjan

Cysticercosis is one of the main causes of secondary epilepsy in sub-Saharan Africa. To estimate the seroprevalence of cysticercosis among epileptic patients, we conducted a cross-sectional study of patients attending neurology consultation in Abidjan, Côte d'Ivoire. Methods: Patients' socio-demographic and lifestyle data were collected as well as blood samples for serological testing using ELISA and Western blot based on IgG antibodies detection. For qualitative variables comparison, Chi2 or Fisher tests were used; a Student's t-test was used to compare quantitative variables. A multivariate logistic regression model was fit to identify risks factors. Results: Among 403 epileptic patients included in the study, 55.3% were male; the median age was 16.9 years; 77% lived in Abidjan; 26.5% were workers. Most patients included in the study had tonic-clonic seizures (80%), and 11.2% had focal deficit signs. The seroprevalence of cysticercosis was 6.0%. The risk was higher in patients over 30 years old (aOR = 5.1 (1.3-20.0)) than in patients under 16. The risk was also considerably high in patients who reported epileptics in the family (aOR = 5 (1.7-14.6)). The risk was three-fold less in females than in males. Conclusions: This study highlighted the exposure of epileptic patients to Taenia solium larvae in an urban area. The risk of positive serology was increased with age, male gender, and family history of epilepsy.

Mortality in Parenchymal and Subarachnoid Neurocysticercosis

Neurocysticercosis (NCC) is endemic in many parts of the world, carrying significant neurological morbidity that varies according to whether lesions are located inside the cerebral parenchyma or in extraparenchymal spaces. The latter, in particular subarachnoid NCC, is assumed to be more severe, but no controlled studies comparing mortality between types of NCC exist. The aim of this study was to compare all-cause mortality between patients with intraparenchymal NCC and those with subarachnoid NCC. Vital status and sociodemographic characteristics were evaluated in patients with intraparenchymal viable, intraparenchymal calcified, and subarachnoid NCC attending a neurological referral hospital in Lima, Perú. Survival analyses using Kaplan-Meier curves and Cox proportional regression models were carried out to compare mortality rates between groups. From 840 NCC patients followed by a median time of 82.3 months, 42 (5.0%) died, six (1.8%) in the intraparenchymal viable group, four (1.3%) in the calcified group, and 32 (16.6%) in the subarachnoid group (P < 0.001). Older age and lower education were significantly associated with mortality. The age-adjusted hazard ratio for death in the subarachnoid group was 13.6 (95% CI: 5.6-33.0, P < 0.001) compared with the intraparenchymal viable group and 10.7 (95% CI: 3.7-30.8, P < 0.001) when compared with the calcified group. We concluded that subarachnoid disease is associated with a much higher mortality in NCC.

Risk factors and prevalence of taeniasis among the Karen people of Tha Song Yang District, Tak Province, Thailand

Taeniasis remains a prevalent public health problem in Thailand. National helminthiasis surveys report only the incidence of Taenia spp. eggs. The ability to differentiate Taenia species using morphological and molecular techniques is vital for epidemiological surveys. This study detected taeniasis carriers and other helminthic infections by Kato's thick smear technique and identified the Taenia species by multiplex PCR. The study subjects were the ethnic Karen people in Tha Song Yang District, Tak Province, Thailand, bordering Myanmar. In total, 983 faecal samples from villagers were examined for helminthiases. Interview-based questionnaires were used to gather information on possible risk factors for infection. The prevalence of helminth infections was 42.7% (420/983), including single (37.3%, 367/983) and mixed infections (5.4%, 53/983). The most common infection (19.23%, 189/983) was Ascaris lumbricoides, whereas taeniasis carriers comprised 2.8% (28/983). Multiplex PCR of Cox1 was used for species identification of Taenia tapeworms, eggs, or both in 22 taeniasis carriers. Most of the parasites (20 cases) were Taenia solium, with two cases of Taenia saginata. Taenia saginata asiatica was not found in the villagers examined. The analysis of 314 completed questionnaires showed that a statistically significant (p < 0.05) risk of taeniasis was correlated with being male, a history of being allowed to forage during childhood, a history of seeing tapeworm proglottids, and a history of raw or undercooked pork consumption. Health education programmes must seek to reduce and prevent reinfection in these communities.

The impact of COVID-19 pandemic on frail health systems of low- and middle-income countries: The case of epilepsy in the rural areas of the Bolivian Chaco

INTRODUCTION

The Coronavirus disease 2019 (COVID-19) has put some health systems under pressure, especially in low- and middle-income countries. We aimed at evaluating the impact of COVID-19 emergency on the management of people with epilepsy (PWE) living in the rural communities of the Gran Chaco area of the Plurinational State of Bolivia.

MATERIALS AND METHODS

We selected a sample of PWE living in the rural communities of the Bolivian Chaco. A standardized questionnaire was developed, consisting of six questions addressing drug availability, drug discontinuation, personnel responsible for drug retrieval during the lockdown, and the presence of seizures in the two months preceding the interview. Questionnaires were administered by community health workers of the rural health centers in September 2020.

RESULTS

Seventy PWE (38 men, 54.3%; mean age 26.9 ± 16.7) were interviewed. During the lockdown the large majority of them (n = 51, 73.9%) reported an irregular medication intake mainly due to the lack of antiseizure medications in the local health posts, leading to an increase in seizure frequency.

CONCLUSION

The COVID-19 pandemic has unmasked the frailty of the Bolivian health system, especially for the management of chronic diseases such as epilepsy in the rural communities.

High frequency of Taenia solium antigen positivity in patients admitted for neurological disorders in the Rural Hospital of Mosango, Democratic Republic of Congo

Background

The epidemiology of human cysticercosis and neurocysticercosis, caused by the larval stage of the pork tapeworm Taenia solium, is not well known in the Democratic Republic of Congo (DRC). Within a multicenter etiological and diagnostic study conducted by the NIDIAG consortium (“Better Diagnosis for Neglected Infections”) and investigating several challenging syndromes, we consecutively evaluated from 2012 to 2015 all patients older than 5 years presenting with neurological disorders (neurology cohort) and with fever > 7 days (persistent fever cohort) at the rural hospital of Mosango, province of Kwilu, DRC. In both cohorts, etiological diagnosis relied on a systematic set of reference laboratory assays and on pre-established clinical case definitions. No neuroimaging was available in the study hospital. In this study, we determined the frequency of T. solium infection in both cohorts and explored in the neurology cohort its association with specific neurological presentations and final etiological diagnoses.

Methods

We conducted a post-hoc descriptive and analytic study on cysticercosis in the neurology and persistent fever cohorts, based on the presence in serum samples of circulating T. solium antigen using the B158/B60 enzyme-linked immunosorbent assay (ELISA) and of cysticercosis IgG using the LDBIO Cysticercosis Western Blot IgG assay.

Results

For the neurology cohort, 340 samples (of 351 enrolled patients) were available for analysis (males: 46.8%; mean age: 38.9 years). T. solium antigen positivity was found in 43 participants (12.6%; 95% confidence interval [CI] 9.3–16.7%), including 9 of 60 (15%) patients with epilepsy. Among the 148 samples available from the persistent fever cohort (males: 39.9%; mean age: 19.9 years), 7 were positive in the T. solium antigen ELISA (4.7%; 95% CI 1.9–9.5%; P = 0.009 when compared to the neurology cohort). No significant association was found within the neurology cohort between positivity and clinical presentation or final diagnoses. Of note, the IgG antibody-detecting assay was found positive in only four (1.3%) of the participants of the neurology cohort and in none of the persistent fever cohort.

Conclusions

T. solium antigen positivity was found in at least 10% of patients admitted with neurological disorders in the Kwilu province, DRC, with no specific pattern of presentation. Further neuroimaging studies should be used to confirm whether neurocysticercosis is prevalent in this region.

Prevalence and incidence of epilepsy in Latin America and the Caribbean: A systematic review and meta-analysis of population-based studies

OBJECTIVE

This study was undertaken to perform an updated systematic review and meta-analysis to estimate the pooled prevalence and incidence of epilepsy in Latin America and the Caribbean (LAC), describing trends over time, and exploring potential clinical and epidemiological factors explaining the heterogeneity in the region.

METHODS

Observational studies assessing the incidence or prevalence of epilepsy in LAC countries up to March 2020 were systematically reviewed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Meta-analyses and cumulative analyses were performed using random-effects models. We assessed between-study heterogeneity with sensitivity, subgroup, and meta-regression analyses. Moreover, the quality of the included studies and the certainty of evidence were evaluated using the GRADE (grading of recommendation, assessment, development, and evaluation) approach.

RESULTS

Overall, 40 studies (from 42 records) were included, 37 for prevalence analyses and six for incidence (312 387 inhabitants; 410 178 person-years). The lifetime prevalence was 14.09 per 1000 inhabitants (95% confidence interval [CI] = 11.72-16.67), for active epilepsy prevalence was 9.06 per 1000 individuals (95% CI = 6.94-11.44), and the incidence rate was 1.11 per 1000 person-years (95% CI = .65-1.70). These high estimates have been constant in the region since 1990. However, substantial statistical heterogeneity between studies and publication bias were found. The overall certainty of evidence was low. Methodological aspects (sample size) and countries' epidemiological characteristics such as access to sanitation services and child and adult mortality rates explained the high heterogeneity. Finally, the prevalence of epilepsy associated with neurocysticercosis (NCC) in the general population was high, and the proportion of NCC diagnosis among people living with epilepsy was 17.37%.

SIGNIFICANCE

The epilepsy prevalence and incidence in LAC are higher than worldwide estimates, being constant since 1990 and strongly influenced by NCC. We identified high between-study heterogeneity and significant methodological limitations (e.g., heterogeneous definitions, lack of longitudinal studies). The region needs upgraded research using standardized definitions and diagnostic methods, and urgent action against preventable causes.

A prospective cohort study to assess the frequency and risk factors for calcification in single lesion parenchymal neurocysticercosis

BACKGROUND

Calcified neurocysticercosis (NCC) predisposes patients to an enduring state of epilepsy. The predictors for calcification in parenchymal neurocysticercosis are not well defined.

METHOD

In this prospective cohort study, consecutive children with single-lesion parenchymal NCC were enrolled and followed up for one year. All patients were investigated with brain 3 T-MRI and electroimmunotransfer blot (EITB). Clinical follow-ups were performed every 3 months. Radiology was repeated at the 6-month and one-year follow-ups. The proportion of calcified lesions at one year and the predictors of calcification were studied.

RESULT

During the study period from June 2013 to December 2015, 93 children with single lesion parenchymal NCC were enrolled. At presentation, 90 % of the lesions were in the colloidal stage, and 71 % of the lesions had moderate to severe perilesional oedema. All children had 6 months of follow-up, and 86 (92.5 %) had one year of follow-up. Seizure recurrence was present in 13 (14 %) children. Follow-up radiology at one year showed lesion resolution in 51 (59 %) lesions and calcification in 28 (32.5 %) lesions. Children with calcified lesions during follow-up had a higher odds of seizure recurrences {OR, 95 % CI 3.6(2.3-5.6)}. The presence at baseline of diffusion restriction {OR, 95% CI 2.9 (1.01-8.8)}, scolex or wall calcification in the T2 Star weighted angiography MRI images {OR, 95% CI 3.7 (1.7-8.2)} and >10 mm size of the lesion {OR, 95 % CI 2.4 (1.2-5.01)} predicted lesion calcification.

CONCLUSION

Children with calcification of the parenchymal NCC lesions have a higher risk for seizure recurrence during follow-up. The presence of diffusion restriction, calcified nidus in the colloidal nodular stage, and >10 mm size of the lesion at baseline predicted calcification of the lesion during follow-up.

Neurocysticercosis in Northern Peru: Qualitative Insights from men and women about living with seizures

BACKGROUND

Neurocysticercosis (NCC) is a helminthic disease of the central nervous system, and it is one of the leading causes of seizures and symptomatic epilepsy in countries with tropical regions like Peru. Studies of people with epilepsy in Peru's northern coast have consistently found that between 30% and 50% of epilepsy cases is associated with NCC. There are few studies that report on the differences in incidence and prevalence of NCC by sex, and to our knowledge, none that consider the gendered dimensions of having epilepsy.

METHODOLOGY

This qualitative study based on individual interviews (n = 9) and focus group discussions (n = 12) explored the challenges of diagnosis and the implications for everyday activities among men and women with epilepsy as well as the views of their family members on the impact of such condition.

PRINCIPAL FINDINGS

The explanatory models used by women to discuss their condition reflect low levels of decision-making power in areas such a reproductive health, health care access and treatment. For some women domestic violence is also a probable cause for seizures among women. The implications of living with neurocysticercosis and the accompanying seizures were reported differently by men and women. While women were mostly concerned about their capacity to perform their domestic responsibilities and their roles as mothers and caregivers; men were mostly concerned about the impact on their income generation activities. Women and men shared concern about the consequences of their condition on the wellbeing of their families.

CONCLUSIONS/SIGNIFICANCE

NCC is a disrupting experience for men and women in ways that reflect their position and roles in society: Women as caregivers within the home, men as income generators outside the home. Further gender research is needed to better understand and address the differential impacts of NCC and health system responses as well as gendered dimensions of prevalence and incidence. (268 words).

Why are epilepsy mortality rates rising in the United States? A population-based multiple cause-of-death study

INTRODUCTION

Epilepsy mortality rates are rising. It is unknown whether rates are rising due to an increase in epilepsy prevalence, changes in epilepsy causes of death, increase in the lethality or epilepsy or failures of treatment. To address these questions, we compare epilepsy mortality rates in the USA with all-cause and all-neurological mortality for the years 1999 to 2017.

OBJECTIVES

To determine changes in US epilepsy mortality rates versus all-cause mortality, and to evaluate changes in the leading causes of death in people with epilepsy.

DESIGN

Retrospective population-based multiple cause-of-death study.

PRIMARY OUTCOME

Change in age-adjusted epilepsy mortality rates compared with mortality rates for all-cause and all-neurological mortality.

SECONDARY OUTCOME

Changes in the leading causes of death in epilepsy.

RESULTS

From 1999 to 2017, epilepsy mortality rates in the USA increased 98.8%, from 5.83 per million in 1999 to 11.59 per million (95% CI 88.2%-110.0%), while all-cause mortality declined 16.4% from 8756.34 per million to 7319.17 per million (95% CI 16.3% to 16.6%). For the same period, all-neurological mortality increased 80.8% from 309.21 to 558.97 per million (95% CI 79.4%-82.1%). The proportion of people with epilepsy who died due to neoplasms, vascular dementia and Alzheimer's increased by 52.3%, 210.1% and 216.8%, respectively. During the same period, the proportion who died due to epilepsy declined 27.1%, while ischaemic heart disease as a cause of death fell 42.6% (p<0.001).

CONCLUSIONS

Epilepsy mortality rates in the USA increased significantly from 1999 to 2017. Likely causes include increases in all-neurological mortality, increased epilepsy prevalence and changes in the underlying causes of death in epilepsy, led by increases in vascular dementia and Alzheimer's. An important finding is that ischaemic heart disease and epilepsy itself are declining as underlying causes of death in people with epilepsy.

Neurocysticercosis-related seizures in the post-partum period: two cases and a review of the literature

Neurocysticercosis, the infection of the CNS with larval cysts of Taenia solium, is a leading cause of seizures in low-income countries. The clinical presentation of neurocysticercosis is variable and depends on the number, size, and location of cysticerci, and on the immune response of the host. In most patients, the affected site is the brain parenchyma, where cysts can precipitate seizures. Neurocysticercosis has seldom been described in pregnant women. In this Grand Round, we report two cases of pregnant women who immigrated to Italy from Bolivia and Ecuador, and who developed seizures in the early post-partum period, due to calcified parenchymal neurocysticercosis lesions. We discuss the complex interactions between neurocysticercosis and the immune system in pregnancy and the post-partum period. Building on this scenario, we propose practices for the management of neurocysticercosis in pregnancy and the post-partum period, highlighting important gaps in the literature that should be addressed.

Unique Characteristics of Epilepsy Development in Neurocysticercosis

The parasitic helminth infection neurocysticercosis (NCC) is the most common cause of adult-acquired epilepsy in the world. Despite the serious consequences of epilepsy due to this infection, an in-depth review of the distinct characteristics of epilepsy due to neurocysticercosis has never been conducted. In this review, we evaluate the relationship between NCC and epilepsy and the unique characteristics of epilepsy caused by NCC. We also discuss recent advances in our understanding of NCC-related epilepsy, including the importance of anti-inflammatory therapies, the association between NCC and temporal lobe epilepsy, and the recent discovery of biomarkers of severe epilepsy development in individuals with NCC and seizures.

Neuroemergencies in South America: How to Fill in the Gaps?

South America is a subcontinent with 393 million inhabitants with widely distinct countries and diverse ethnicities, cultures, political and societal organizations. The epidemiological transition that accompanied the technological and demographic evolution is happening in South America and leading to a rise in the incidence of neurodegenerative and cardiovascular diseases that now coexist with the still high burden of infectious diseases. South America is also quite heterogeneous regarding the existence of systems of care for the various neurological emergencies, with some countries having well-organized systems for some diseases, while others have no plan of action for the care of patients with acute neurological symptoms. In this article, we discuss the existing systems of care in different countries of South America for the treatment of neurological emergencies, mainly stroke, status epilepticus, and traumatic brain injury. We also will address existing gaps between the current systems and recommendations from the literature to improve the management of such emergencies, as well as strategies on how to solve these disparities.

Neurocysticercosis in people with epilepsy in Sub-Saharan Africa: A systematic review and meta-analysis of the prevalence and strength of association

PURPOSE

We analyzed studies on neurocysticercosis (NCC) and epilepsy across Sub-Saharan Africa (SSA) to determine the prevalence of NCC in people with epilepsy (PWE) and the strength of association of NCC with epilepsy in the region.

METHODS

We conducted a systematic review of the existing literature on NCC and epilepsy in SSA. Diagnostic methods for NCC in the studies selected for our analysis included one or more of the following: positive brain CT, serum ELISA and serum EITB. A common prevalence and overall odds-ratio were then estimated using meta-analysis.

RESULTS

A total of 25 (overall) and 20 (case-control) studies met the inclusion criteria for the prevalence and strength of association estimation, respectively. The overall prevalence estimate of NCC in PWE was 22 % [95 % confidence interval [CI]: 17-27.0 %). The figures were higher in the Southern and Eastern Africa sub-region (45 % and 25 % respectively) but lower in the Central and Western Africa sub-region (6 % and 15 % respectively). The prevalence of NCC estimate in PWE varied with method of diagnosis; with 29 % 18 % and 15 % in studies that used a minimum of Brain CT, ELISA and EITB respectively. The overall odds ratio was 2.4 (95 % CI 2.1-2.8), p < 0.0001.

CONCLUSION

The overall prevalence of NCC in PWE in SSA was 22 %. The prevalence figure varied with the sub-region of SSA. The odd of NCC in PWE in SSA was 2.4. In spite of the sub-regional variation in NCC prevalence, this meta-analysis suggests that neurocysticercosis contributes significantly to epilepsy in SSA.

Taenia solium cysticercosis and taeniasis in urban settings: Epidemiological evidence from a health-center based study among people with epilepsy in Dar es Salaam, Tanzania

In Africa, urbanization is happening faster than ever before which results in new implications for transmission of infectious diseases. For the zoonotic parasite Taenia solium, a major cause of acquired epilepsy in endemic countries, the prevalence in urban settings is unknown. The present study investigated epidemiological, neurological, and radiological characteristics of T. solium cysticercosis and taeniasis (TSCT) in people with epilepsy (PWE) living in Dar es Salaam, Tanzania, one of the fastest growing cities worldwide. A total of 302 PWE were recruited from six health centers in the Kinondoni district of Dar es Salaam. Serological testing for T. solium cysticercosis-antigen (Ag) and -antibodies (Abs) and for T. solium taeniasis-Abs was performed in all PWE. In addition, clinical and radiological examinations that included cranial computed tomography (CT) were performed. With questionnaires, demographic data from study populations were collected, and factors associated with TSCT were assessed. Follow-up examinations were conducted in PWE with TSCT. T. solium cysticercosis-Ag was detected in three (0.99%; 95% CI: 0–2.11%), -Abs in eight (2.65%; 95% CI: 0.84–4.46%), and taeniasis-Abs in five (1.66%; 95% CI: 0.22–3.09%) of 302 PWE. Six PWE (1.99%; 95% CI: 0.41–3.56%) were diagnosed with neurocysticercosis (NCC). This study demonstrates the presence of TSCT in Dar es Salaam, however, NCC was only associated with a few cases of epilepsy. The small fraction of PWE with cysticercosis- and taeniasis-Abs may suggest that active transmission of T. solium plays only a minor role in Dar es Salaam. A sufficiently powered risk analysis was hampered by the small number of PWE with TSCT; therefore, further studies are required to determine the exact routes of infection and risk behavior of affected individuals.

Taenia solium cysticercosis and taeniasis is a zoonotic disease complex which affects thousands of people in sub-Saharan Africa. This parasite has a human-pig life cycle and has been considered a public health problem mainly in rural areas. As African towns and suburbs grow rapidly and disproportionally, adequate infrastructure such as sewage systems and clean water often lack while population density, trade, and travel increase. This may lead to the appearance of parasitic diseases formerly considered `rural´ in urban settings. In this study, we searched for evidence of T. solium infections in the Kinondoni district of Dar es Salaam, Tanzania. We focused on people with epilepsy (PWE) since epilepsy is one of the most common and severe disorders associated with T. solium neurocysticercosis and tested all of them serologically for T. solium cysticercosis and taeniasis. We further investigated neurological and radiological characteristics. Our findings show that in our study area in Dar es Salaam 2.65% of PWE had contracted T. solium infection at some stage. Neurocysticercosis, as confirmed by neuroimaging, was found only in 1.99% of PWE. This, in combination with the relatively small number of PWE detected with taeniasis antibodies (1.66%), points towards the fact that active transmission of T. solium seems to play only a minor role in this urban setting, suggesting that infections may mainly be contracted in rural areas. Further large-scale studies are required to investigate the infection pathways and risk behavior related to T. solium infections within urban areas of sub-Saharan Africa.

Prenatal exposure to oxcarbazepine increases hippocampal apoptosis in rat offspring

This study assessed apoptosis in the offspring of rats exposed to oxcarbazepine (OXC) from day 7 to 15 of gestation. Three groups of pregnant Wistar rats were used: 1) Control, treated with saline solution; 2) treated with 100 mg/kg OXC; 3) treated with 100 mg/kg of carbamazepine (CBZ, as a positive control for apoptosis); the route of administration was intragastric. Apoptosis was detected at three postnatal ages using the TUNEL technique in the CA1, and CA3 regions of the hippocampus and in the dentate gyrus (DG); neurogenesis was assessed in the DG using an antibody against doublecortin. The litter characteristics were recorded. OXC increased apoptosis in all regions (p < 0.01) at the three ages evaluated. Lamination disruption occurred in CA1 and CA3 due to the neuron absence and to ectopic neurons; there were also malformations in the dorsal lamina of the DG in 38% and 25% of the pups born from rats treated with OXC and CBZ respectively. CBZ also increased apoptosis. No clear effect on neurogenesis in the DG was observed. The size of the litter was smaller (p < 0.01) in the experimental groups. Nineteen-day OXC fetuses had low weight (p < 0.01), but 21 and 30 postnatal days old CBZ and OXC pups were overweight (p < 0.01). The results demonstrate that OXC administered during gestation is pro-apoptotic, alters the cytoarchitecture of the hippocampus, reduces litter size, and probably influences postnatal weight. We provide evidence of the proapoptotic effect of CBZ when administered early in gestation.

Screening for neurocysticercosis in internationally adopted children: yield, cost and performance of serological tests, Italy, 2001 to 2016

Neurocysticercosis (NCC) is one of the leading causes of epilepsy worldwide. The majority of cases in Europe are diagnosed in immigrants. Currently in Italy, routine serological screening for cysticercosis is recommended for internationally adopted children (IAC) coming from endemic countries. Methods: We retrospectively analyse the results of the serological screening for cysticercosis in IAC 16 years old or younger, attending two Italian third level paediatric clinics in 2001–16. Results: Of 2,973 children included in the study, 2,437 (82.0%) were screened by enzyme-linked immune electro transfer blot (EITB), 1,534 (51.6%) by ELISA, and 998 (33.6%) by both tests. The seroprevalence of cysticercosis ranged between 1.7% and 8.9% according to EITB and ELISA, respectively. Overall, 13 children were diagnosed with NCC accounting for a NCC frequency of 0.4% (95% confidence interval (CI): 0.2–0.6%). Among the 168 seropositive children, only seven (4.2%) were diagnosed with NCC. Of these children, three were asymptomatic and four presented epilepsy. Among seronegative children (n = 2,805), seven presented with neurological symptoms that lead to the diagnosis of NCC in six cases. The sensitivity, specificity, positive and negative predictive value for the diagnosis of NCC were 54.5%, 98.6%, 14.6%, 99.8% for EITB and 22.2%, 91.1%, 1.4%, 99.5% for ELISA. The yield of the screening programme was 437 NCC cases per 100,000. The number needed to screen to detect one NCC case was 228. The cost per NCC case detected was EUR 10,372. Conclusion: On the base of our findings we suggest the ongoing serological screening for cysticercosis to be discontinued, at least in Italy, until further evidence in support will be available.

Prevalence, clinical characteristics, and seizure outcomes of epilepsy due to calcific clinical stage of neurocysticercosis: Study in a rural community in south India

OBJECTIVE

The objective of this research was to study the prevalence, clinical characteristics, and seizure remission rates of epilepsy due to calcific stage of neurocysticercosis (cNCC) in a rural community in south India.

MATERIAL AND METHODS

Comprehensive Rural Epilepsy Study South India (CRESSI) is a prospective longitudinal study of epilepsy care in a rural community in south India. As part of this study, prevalence of epilepsy was studied in a population of 74,086 in 22 villages. The prevalence study identified 451 people with epilepsy including 62 (13.7%) with epilepsy due to cNCC. Diagnosis of cNCC was based on computed tomography (CT) findings. The clinical characteristics and seizure outcomes were studied in this cohort of 62 patients. The data collected included demographics, seizure type, antiepileptic drugs (AEDs), seizure remission rates, and predictors of long-term seizure remissions.

RESULTS

The crude prevalence of epilepsy due to cNCC in this rural community was 0.84 per 1000 (95% confidence interval [CI]: 0.65-1.07). This lesion accounted for 41% of the established etiology among 451 prevalence cases of epilepsy. Mean age at presentation was 28.87 ± 14.45 (range: 8-65 years) with equal gender distribution. The common location of the lesion was in the perirolandic region. Focal onset motor seizures were the common seizure type. Seizure remission (≥2 years) rate was 80.3%. The independent predictor of drug resistance was failure to respond to monotherapy (odds ratio: 63.9; 95% CI: 8.4-485.4; p < 0.0001). Focal impaired awareness behavioral arrest/automatisms with lesion located in the temporal lobe in all the three patients were drug-resistant.

CONCLUSIONS

In this rural community in south India, epilepsy due to cNCC was the commonest acquired epilepsy in people aged ≥20 years. Long-term seizure remission rates were high, and failure to respond to monotherapy was the predictor of drug resistance. Drug-resistant epilepsy was extremely rare with this lesion.

Convulsive status epilepticus due to different evolutionary stages of neurocysticercosis - solitary cyticercus granuloma, low cyst load, and single calcific lesion in an endemic country: Clinical profile

PURPOSE

The aims of the study were: (a) to evaluate the clinical profile of convulsive status epilepticus (CSE) due to different evolutionary stages of neurocysticercosis (NCC), solitary cysticercus granuloma, low cyst load and single calcific lesion in an endemic country; (b) to evaluate the response of CSE to antiepileptic drugs; and (c) to evaluate long-term outcomes METHODS: A retrospective review of case records of patients with CSE due to different evaluative stages of NCC seen over a period of 18 years.

RESULTS

During 18 years period, 41 (24 males, mean age 25.3 years, range 8-65 years) patients with CSE due to different evolutionary stages of NCC were admitted to our Neurological Intensive Care Unit. There were 7 patients with 3-5 degenerative cyst load, 20 with solitary cysticercus granuloma (SCG), and 14 with single calcific (cNCC) lesion. Of the 41 patients, CSE was the initial presenting feature in 38 (93%) patients. The mean duration of CSE was 5.85 h (range 0.5-48 h). The mean duration of CSE due to single cNCC was significantly shorter when compared to the duration of CSE due to degenerative stages of NCC (1.96 + 1.39 h vs. 7.87+13.18; p < 0.026). Of the 41 patients, 39 (95%) responded to first-line treatment (intravenous (IV) benzodiazepine followed by IV phenytoin/ fosphenytoin or valproate), two patients required continuous IV midazolam. Both the patients developed aspiration pneumonia. There were no deaths, and all the 41 patients had Glasgow Outcome Score of 5 at 90-day follow-up and were back to their previous occupation.

CONCLUSIONS

This study suggests that CSE due to different evolutionary stages of NCC, SCG, low lesional load, and single calcific lesion is rare even in countries endemic to NCC and is associated with an excellent outcome.