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.

Current Consensus Guidelines for Treatment of Neurocysticercosis

Neurocysticercosis is now recognized as a common cause of neurologic disease in developing countries and the United States. The pathogenesis and clinical manifestations vary with the site of infection and accompanying host response. Inactive infection should be treated symptomatically. Active parenchymal infection results from an inflammatory reaction to the degenerating cysticercus and will also respond to symptomatic treatment. Controlled trials have not demonstrated a clinical benefit for antiparasitic drugs. Ventricular neurocysticercosis often causes obstructive hydrocephalus. Surgical intervention, especially cerebrospinal fluid diversion, is the key to management of hydrocephalus. Shunt failure may be less frequent when patients are treated with prednisone and/or antiparasitic drugs. Subarachnoid cysticercosis is associated with arachnoiditis. The arachnoiditis may result in meningitis, vasculitis with stroke, or hydrocephalus. Patients should be treated with corticosteroids, antiparasitic drugs, and shunting if hydrocephalus is present.

Neurocysticercosis: Updates on Epidemiology, Pathogenesis, Diagnosis, and Management

Neurocysticercosis (NC) remains a major public health problem in developing and some developed countries. Currently, the best procedures for diagnosing NC are neuroimaging studies. Immunoserologic assays, such as enzyme-linked immunoelectrotransfer blot assay (EITB) or enzyme-linked immunosorbent assay (ELISA), detect antibodies against Taenia solium, or cysticercus. Consequently, they are useful in identifying a population at risk of contact with the parasite but do not necessarily indicate a systemic active infection. Most seropositive individuals are asymptomatic. No data from prospective studies concern the proportion of these individuals that will develop seizures or other neurologic symptoms. There is a discrepancy between the results of serologic assays and neuroimaging studies: >50% of those individuals with NC diagnosed by computed tomography (CT) scan test EITB negative. Pathophysiologic classification of NC into active, transitional, and inactive forms permits a good correlation between clinical manifestations and neuroimaging procedures and facilitates medical and surgical management and research. The most frequent clinical manifestations of NC are seizures. We assume that NC is the main cause of symptomatic epilepsy in developing countries; however, no case-control or cohort studies demonstrate this association. Most patients with NC with seizures have a good prognosis; nevertheless, further studies analyzing factors related to recurrence of seizures and possibilities of discontinuation of antiepileptic medications (AEDs) are needed. Regarding treatment of NC with antihelminthic drugs, no controlled clinical trials exist that establish specific indications, definitive doses, and duration of treatment. The most effective approach to taeniasis/cysticercosis infection is prevention. This should be a primary public health focus for developing countries. We critically review the available information regarding the epidemiology and diagnosis of human cysticercosis, the physiopathology and imaging correlation of the parasite in the central nervous system (CNS) of the host, the relation between seizures or epilepsy and NC, and the issues surrounding the treatment and prognosis of NC, including the use of antihelminthic therapy.

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Cysticercosis and epilepsy: a critical review.

Cysticercosis is the commonest parasitic disease of the central nervous system and is endemic not only in developing countries but in industrialized nations with high rates of immigration from endemic areas. Clinical manifestations of neurocysticercosis are non-specific and depend mainly on the number and the topography of the lesions, the host immune response to the parasite, and the sequelae of previous infections. Diagnosis is difficult on clinical grounds, but integration of data from computed tomography and cerebrospinal fluid analysis permits accurate diagnosis of most cases. Therapy for neurocysticercosis is also varied and must be individualized according to the activity of the disease and location of cysticerci. In this paper, the experience of the authors with neurocysticercosis is summarized and current information on several controversial aspects of this disease is reviewed.

Neurocysticercosis: An Update

Background
The clinical manifestations of neurocysticercosis (NCC) are poorly understood. This systematic review aims to estimate the frequencies of different manifestations, complications and disabilities associated with NCC.

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Clinical manifestations associated with neurocysticercosis: a systematic review

OBJECTIVE: To determine the frequency and features of psychiatric morbidity in a cross section of 38 outpatients with neurocysticercosis. METHODS: Diagnosis of neurocysticercosis was established by CT, MRI, and CSF analysis. Psychiatric diagnoses were made by using the present state examination and the schedule for affective disorders and schizophrenia-lifetime version; cognitive state was assessed by mini mental state examination and Strub and Black's mental status examination. RESULTS: Signs of psychiatric disease and cognitive decline were found in 65.8 and 87.5% of the cases respectively. Depression was the most frequent psychiatric diagnosis (52.6%) and 14.2% of the patients were psychotic. Active disease and intracranial hypertension were associated with higher psychiatric morbidity, and previous history of mood disorders was strongly related to current depression. Other variables, such as number and type of brain lesions, severity of neuropsychological deficits, epilepsy, and use of steroids did not correlate with mental disturbances in this sample. CONCLUSIONS: Psychiatric abnormalities, particularly depression syndromes, are frequent in patients with neurocysticercosis. Although regarded as a rare cause of dementia, mild cognitive impairment may be a much more prevalent neuropsychological feature of patients with neurocysticercosis. The extent to which organic mechanisms related to brain lesions may underlie the mental changes is yet unclear, although the similar sex distribution of patients with and without depression, as well as the above mentioned correlations, provide further evidence of the part played by organic factors in the cause of these syndromes.

https://jnnp.bmj.com/content/jnnp/62/6/612.full.pdf

Psychiatric manifestations of neurocysticercosis: a study of 38 patients from a neurology clinic in Brazil.

Report of the observations of 40 patients suffering from neurocysticercosis, submitted to treatment by praziquantel, administered per os. Dexamethasone was associated to praziquantel in 20 patients. Side effects observed had a transient character. Transient exacerbation or reappearance of the cerebrospinal fluid neurocysticercosis syndrome, both related to the periods of treatment, can be considered an indirect rating of praziquantel action on cysticerci. This episode was observed in 31 patients. Dexamethasone proved sufficient to reduce the intensity of these episodes and of the effects. Evaluation of the 20 patients suffering from forms of the disease characterized by intracranial hypertension, and who had a follow-up of more than 3 months (up to 19 months) showed: disappearance of corticoid-dependence (5/5); disappearance of ventricular dilatation (4/6) appearance or increase inthe number of nodular calcifications (3/6); non-occurrence of new outbreaks of intracranial hypertension in 15 of the 20 cases. Repetitive characteristics of the clinical symptomatology, call for a longer-period observation of patients to allow for conclusion as to the effectiveness of the drug in the treatment of neurocysticercosis.

Administration of praziquantel in neurocysticercosis

To outline through cinical-laboratorial analysis a profile of schistosomiasis of the spinal cord (SSC) that contributes to the diagnosis and treatment of this disease. 80 patients were studied (59 prospectively), and epidemiological, clinical,laboratorial, treatment and outcome data extracted. In 79 patients the diagnosis was presumptive and obeyed rigorous criteria. There was a predominance of male sex (68.7%), age group from 21 to 40 years (63.7%), Northeasterners (85%), building construction workers (31.2%), previous abdominal effort (57.5%), subacute beginning (61.2%), myeloradiculitis form and lesion in conus and cauda equina (72.5%). Cerebral spinal fluid showed lymphomononuclear pleocytosis and protein increase in 100% of the cases as well as gamma globulin in 76.5%, positiveness of immunofluorescence reaction and/or ELISA for schistosomiasis in 100% of the cases with average titles of 1/16 and 61 u/dl, respectively. Corticosteroids and antischistosomal drugs were given to all patients with a satisfactory outcome in 80% of the cases. We emphasize the importance of a precocious treatment to avoid irreversible deficits such as paraplegia or sexual impotence.

https://www.arquivosdeneuropsiquiatria.org/wp-content/uploads/articles_xml/1678-4227-anp-S0004-282X2002000400016/1678-4227-anp-S0004-282X2002000400016.pdf

Esquistossomose medular: análise de 80 casos

Three hundred land fifty seven computed tomography (CT) from 100 different patients with neurocysticercosis (NC) were studied between 1979 and 1988. All patients were treated with praziquantel (PZQ). A new classification attempting to recognize the CT evolution profile in NC as well as assigning a possible link between CT findings and biological conditions of cysts is evaluated. It was possible to conclude that: intact cysts remain unchanged in consecutive CTs by 11 months and exhibit signs of degeneration in about 18 months after PZQ drug therapy; degenerating cysts can be detected by 10.5 months, disappear in 11 months and become nodular calcifications in about 25 months. Therefore, a time period of at least 36 months can be estimated for the complete evolution profile of cysts in the brain parenchyma.

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Computed tomography in neurocysticercosis a 10-year long evolution analysis of 100 patients with an appraisal of a new classification

In this preliminary report the authors present the finding of a high prevalence (37.5%) of seropositivity of antibodies to HTLV-I tested by Western blotting in a sample of 16 Brazilian patients with chronic myelopathies of undetermined origin.

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J. P. S. Nobrega

Papers

Psychiatric manifestations of neurocysticercosis: a study of 38 patients from a neurology clinic in Brazil.

Administration of praziquantel in neurocysticercosis

Esquistossomose medular: análise de 80 casos

Computed tomography in neurocysticercosis a 10-year long evolution analysis of 100 patients with an appraisal of a new classification

HTLV-I associated myelopathy in Brazil: a preliminary report.