Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

central nervous system disease: with elevated intracranial pressure

1st line – surgery or corticosteroid

Back
INITIAL
|
central nervous system disease: with elevated intracranial pressure
1st line – 

surgery or corticosteroid

Initial management of patients with neurocysticercosis should focus on treating elevated intracranial pressure as it can be life threatening. Approximately 20% of patients with neurocysticercosis present with elevated intracranial pressure due to either diffuse cerebral oedema (cysticercal encephalitis) or hydrocephalus.[33]

A surgical approach (e.g., ventriculoperitoneal shunting, cerebrospinal fluid diversion, or minimally invasive surgical debulking/cyst removal) is recommended for patients with hydrocephalus.[33]

Corticosteroid therapy is recommended in patients with diffuse cerebral oedema.[33]

Antiparasitic therapy is not recommended until intracranial pressure is stabilised. Use of antiparasitic therapy in patients with elevated intracranial pressure can lead to fatal adverse events (e.g., herniation).[33] Once the patient is stabilised, management depends on the type of neurocysticercosis.

Primary options

dexamethasone sodium phosphate: children: 1.5 mg/kg intravenously/intramuscularly initially, followed by 1 to 1.5 mg/kg/day given in divided doses every 3-4 hours; adults: 10 mg intravenously/intramuscularly initially, followed by 4 mg every 6 hours; give until response then taper dose gradually over 5-7 days and replace with oral treatment when possible

Consider – anticonvulsant

Back
INITIAL
|
central nervous system disease: with elevated intracranial pressure
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

Recommended in all patients with seizures. Management guidelines are similar to those in other patients with seizures.[33]

There are no efficacy data on different anticonvulsants in patients with neurocysticercosis. Choice is guided by availability, drug interactions, adverse effects, and cost. Many anticonvulsants should not be used in pregnant women due to their teratogenic effects.

Can be tapered and stopped after resolution of cysts on magnetic resonance imaging and if the patient is seizure-free for a certain period of time (dependent on the location of cysts), provided they have no risk factors for seizure recurrence. Evidence for the optimal duration of anticonvulsant treatment in patients with neurocysticercosis is limited.[52]​ The World Health Organization recommends considering discontinuation 6 months after the last seizure in patients with a single enhancing lesion and a low risk of seizure recurrence; treatment should be continued for at least 2 years in patients with calcified neurocysticercosis and epilepsy.[39]​ 

ACUTE

intestinal disease

1st line – antiparasitic therapy

Back
ACUTE
|
intestinal disease
1st line – 

antiparasitic therapy

Praziquantel is taken as a single dose. Safety of praziquantel in children under 4 years is unknown and is therefore not recommended.[57] Infection with Hymenolepis nana requires higher doses.

Niclosamide may also be used in adults and children of all ages.

Antiparasitic therapy should be delayed until after delivery in pregnant women.

Primary options

praziquantel: children ≥4 years of age and adults: 5-10 mg/kg orally as a single dose; higher doses of 25 mg/kg as a single dose required in Hymenolepis nana infection

OR

niclosamide: dose depends on type of tapeworm infection; consult specialist for guidance on dose

central nervous system disease: without elevated intracranial pressure

1st line – evaluate for surgery

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
inactive (calcified) parenchymal disease
1st line – 

evaluate for surgery

Surgical removal of seizure foci can be considered in select patients.[33]

Consider – anticonvulsant

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
inactive (calcified) parenchymal disease
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

Recommended in all patients with seizures. Management guidelines are similar to those in other patients with seizures.[33]

There are no efficacy data on different anticonvulsants in patients with neurocysticercosis. Choice is guided by availability, drug interactions, adverse effects, and cost. Many anticonvulsants should not be used in pregnant women due to their teratogenic effects.

Can be tapered and stopped after resolution of cysts on magnetic resonance imaging and if the patient is seizure-free for a certain period of time (dependent on the location of cysts), provided they have no risk factors for seizure recurrence. Evidence for the optimal duration of anticonvulsant treatment in patients with neurocysticercosis is limited.[52]​ The World Health Organization recommends that treatment should be continued for at least 2 years in patients with calcified neurocysticercosis and epilepsy.[39]​ 

1st line – antiparasitic therapy

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
active parenchymal disease
1st line – 

antiparasitic therapy

Antiparasitic therapy is recommended in all patients with viable parenchymal disease. Monotherapy with albendazole is recommended in patients with 1-2 viable cysts or with a single enhancing lesion. Combination therapy with albendazole plus praziquantel is recommended in patients with >2 viable lesions.[33]

Antiparasitic therapy should be delayed until after delivery in pregnant women.

Treatment course: 10-14 days (or 7-14 days for a single enhancing lesion). Re-treatment can be considered in patients with persistent cystic lesions (i.e., still present 6 months after initial course of therapy).

Primary options

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses, maximum 1200 mg/day (800 mg/day in patients with a single enhancing lesion)

OR

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses, maximum 1200 mg/day

and

praziquantel: children ≥4 years of age and adults: 50 mg/kg/day given in 3 divided doses

Plus – corticosteroid

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
active parenchymal disease
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Concurrent corticosteroid therapy can help to control oedema. Treatment should be started 3-4 days before antiparasitic therapy.[33]

Optimal dosing regimens have not been defined. Patients with recent (within 6 months) seizure activity may benefit from an enhanced dexamethasone dosing regimen compared to the standard dose regimen.[53]

Primary options

prednisolone: children and adults: 1-2 mg/kg/day orally

OR

dexamethasone: children: consult specialist for guidance on dose; adults (standard dose): 6 mg/day orally for 10 days; adults (enhanced dose): 8 mg/day orally (3 mg orally in the morning and afternoon and 2 mg in the evening) on days 1-28, followed by a 2-week taper (decrease dose every 2 days to 6 mg/day, 4 mg/day, 3 mg/day, 2 mg/day, and 1 mg/day, then 0.5 mg/day for 4 days, then stop)

Consider – anticonvulsant

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
active parenchymal disease
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

Recommended in all patients with seizures. Management guidelines are similar to those in other patients with seizures.[33]

There are no efficacy data on different anticonvulsants in patients with neurocysticercosis. Choice is guided by availability, drug interactions, adverse effects, and cost. Many anticonvulsants should not be used in pregnant women due to their teratogenic effects.

Can be tapered and stopped after resolution of cysts on magnetic resonance imaging and if the patient is seizure-free for a certain period of time (dependent on the location of cysts), provided they have no risk factors for seizure recurrence. Evidence for the optimal duration of anticonvulsant treatment in patients with neurocysticercosis is limited.[52]​ The World Health Organization recommends that treatment should be continued for at least 2 years in patients with calcified neurocysticercosis and epilepsy.[39]​ 

1st line – surgery

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
intraventricular disease
1st line – 

surgery

Once intracranial pressure is stabilised, neuroendoscopic removal of cysticerci in the lateral and third ventricles is recommended, while surgical removal of cysticerci in the fourth ventricle (i.e., endoscopic or microsurgical cystectomy) is preferred. If surgical removal is not feasible (e.g., adherent cyst), cerebrospinal fluid diversion via a ventriculoperitoneal shunt, along with medical therapy, is recommended.[33]

Patients with magnetic resonance imaging findings of significant ependymal enhancement (secondary to adherence of lesions to the ependyma) may not be suitable for this surgery.[31]

Plus – corticosteroid

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
intraventricular disease
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Concurrent corticosteroid therapy can help to control oedema. Corticosteroids are recommended in the perioperative period, or in combination with antiparasitic therapy after shunt placement.[33]

Optimal dosing regimens have not been defined.

Primary options

prednisolone: children and adults: 1 mg/kg/day orally

OR

dexamethasone: children and adults: 0.2 to 0.4 mg/kg/day orally

Consider – antiparasitic therapy

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
intraventricular disease
Consider – 

antiparasitic therapy

Additional treatment recommended for SOME patients in selected patient group

Patients who have received a shunt should be treated with antiparasitic therapy to reduce the rate of shunt failure. Some experts also recommend antiparasitic therapy after successful surgical removal of ventricular cysts; however, guidelines do not recommend this.[33]

Antiparasitic therapy should be delayed until after delivery in pregnant women.

Treatment course: albendazole is continued for between 8 and 30 days and can be repeated as necessary; praziquantel is given as a higher dose on day 1 and lower doses for 29 consequent days.

Primary options

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses for 8-30 days

OR

praziquantel: children ≥4 years of age and adults:100 mg/kg/day orally given in 3 divided doses for 1 day, followed by 50 mg/kg/day given in 3 divided doses for 29 days

Consider – anticonvulsant

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
intraventricular disease
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

Recommended in all patients with seizures. Management guidelines are similar to those in other patients with seizures.[33]

There are no efficacy data on different anticonvulsants in patients with neurocysticercosis. Choice is guided by availability, drug interactions, adverse effects, and cost. Many anticonvulsants should not be used in pregnant women due to their teratogenic effects.

Can be tapered and stopped after resolution of cysts on magnetic resonance imaging and if the patient is seizure-free for a certain period of time (dependent on the location of cysts), provided they have no risk factors for seizure recurrence. Evidence for the optimal duration of anticonvulsant treatment in patients with neurocysticercosis is limited.[52]​ The World Health Organization recommends considering discontinuation 6 months after the last seizure in patients with a single enhancing lesion and a low risk of seizure recurrence; treatment should be continued for at least 2 years in patients with calcified neurocysticercosis and epilepsy.[39]​ 

1st line – antiparasitic therapy

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
subarachnoid disease
1st line – 

antiparasitic therapy

Subarachnoid cysts do not respond well to typical doses and treatment courses; therefore, prolonged treatment (i.e., several months to more than 1 year) with albendazole, or albendazole plus praziquantel, is recommended.[33]

The endpoint for treatment is not clear, but it is suggested that treatment continue until there is a resolution of lesions on magnetic resonance imaging.

Antiparasitic therapy should be delayed until after delivery in pregnant women.

Primary options

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses

OR

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses

and

praziquantel: children ≥4 years of age and adults: 50 mg/kg/day orally given in 3 divided doses

Plus – corticosteroid

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
subarachnoid disease
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Corticosteroid therapy is essential in these patients to help control the host's inflammatory response to antiparasitic therapy. Prolonged treatment is required in these patients, and the dose should be tapered over time. Treatment should be started before antiparasitic therapy.[33]

Optimal dosing regimens have not been defined.

Primary options

prednisolone: children and adults: 1 mg/kg/day orally

OR

dexamethasone: children and adults: 0.2 to 0.4 mg/kg/day orally

Consider – methotrexate

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
subarachnoid disease
Consider – 

methotrexate

Additional treatment recommended for SOME patients in selected patient group

Methotrexate may be used as a corticosteroid-sparing agent during ongoing treatment with corticosteroids in order to reduce the adverse effects associated with long-term corticosteroid use.[33][48]

Primary options

methotrexate: children and adults: consult specialist for guidance on dose

Consider – anticonvulsant

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
subarachnoid disease
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

Recommended in all patients with seizures. Management guidelines are similar to those in other patients with seizures.[33]

There are no efficacy data on different anticonvulsants in patients with neurocysticercosis. Choice is guided by availability, drug interactions, adverse effects, and cost. Many anticonvulsants should not be used in pregnant women due to their teratogenic effects.

Can be tapered and stopped after resolution of cysts on magnetic resonance imaging and if the patient is seizure-free for a certain period of time (dependent on the location of cysts), provided they have no risk factors for seizure recurrence. Evidence for the optimal duration of anticonvulsant treatment in patients with neurocysticercosis is limited.[52]​ The World Health Organization recommends considering discontinuation 6 months after the last seizure in patients with a single enhancing lesion and a low risk of seizure recurrence; treatment should be continued for at least 2 years in patients with calcified neurocysticercosis and epilepsy.[39]​ 

1st line – consider surgery

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
spinal disease
1st line – 

consider surgery

The mainstay of treatment is case-specific surgery. Management should be individualised based on symptoms, cyst location, degree of arachnoiditis, and experience of the surgeon.[33]

Many spinal cases are in the subarachnoid spine and can be treated with prolonged antiparasitic therapy; however, surgery is indicated if there are symptoms that require decompression.

Plus – antiparasitic therapy

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
spinal disease
Plus – 

antiparasitic therapy

Treatment recommended for ALL patients in selected patient group

Antiparasitic therapy can be considered in addition to surgery. Prolonged treatment (i.e., more than 1 year) with albendazole, or albendazole plus praziquantel, is recommended.[33]

The endpoint for treatment is not clear, but it is suggested that treatment continue until there is a resolution of lesions on magnetic resonance imaging.

Antiparasitic therapy should be delayed until after delivery in pregnant women.

Primary options

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses

OR

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses

and

praziquantel: children ≥4 years of age and adults: 50 mg/kg/day orally given in 3 divided doses

Plus – corticosteroid

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
spinal disease
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Concurrent corticosteroid therapy can help swelling in the spinal cord and control resulting arachnoiditis. It is recommended in patients with evidence of spinal cord dysfunction, including incontinence or paraparesis.[33]

Optimal dosing regimens have not been defined.

Primary options

prednisolone: children and adults: 1 mg/kg/day orally

OR

dexamethasone: children and adults: 0.2 to 0.4 mg/kg/day orally

Consider – anticonvulsant

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
spinal disease
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

Recommended in all patients with seizures. Management guidelines are similar to those in other patients with seizures.[33]

There are no efficacy data on different anticonvulsants in patients with neurocysticercosis. Choice is guided by availability, drug interactions, adverse effects, and cost. Many anticonvulsants should not be used in pregnant women due to their teratogenic effects.

Can be tapered and stopped after resolution of cysts on magnetic resonance imaging and if the patient is seizure-free for a certain period of time (dependent on the location of cysts), provided they have no risk factors for seizure recurrence. Evidence for the optimal duration of anticonvulsant treatment in patients with neurocysticercosis is limited.[52]​ The World Health Organization recommends considering discontinuation 6 months after the last seizure in patients with a single enhancing lesion and a low risk of seizure recurrence; treatment should be continued for at least 2 years in patients with calcified neurocysticercosis and epilepsy.[39]​ 

1st line – surgery

Back
ACUTE
|
central nervous system disease: without elevated intracranial pressure
|
ocular disease
1st line – 

surgery

The mainstay of treatment is case-specific surgery for disease involving the eye.[33]

hepatic or thoracic disease

1st line – surgery

Back
ACUTE
|
hepatic or thoracic disease
1st line – 

surgery

Surgery is usually the mainstay of treatment for echinococcosis patients with CE2 (mother cysts filled with daughter cysts) or CE3b cysts (cysts that have partial solidification with daughter cysts). CE1 cysts (cysts with no daughter cysts) may be good candidates for PAIR (puncture, aspiration, injection, and re-aspiration) procedure. Inactive cysts (those with no daughter cysts on ultrasound [CE4] and calcified cysts [CE5]) should be watched and followed by ultrasound.

Plus – antiparasitic therapy

Back
ACUTE
|
hepatic or thoracic disease
Plus – 

antiparasitic therapy

Treatment recommended for ALL patients in selected patient group

Albendazole is administered concurrently for at least 2 weeks pre-operatively and 1 to 3 months postoperatively.

In pulmonary hydatid disease, prolonging combination therapy of albendazole and praziquantel from 2 weeks to 4 or 8 weeks prior to surgery led to an increased scolicidal response. Prolonging pre-treatment may be considered if the patient is at high risk for intraoperative rupture.[54]

Antiparasitic therapy should be delayed until after delivery in pregnant women.

Primary options

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses

OR

albendazole: children and adults: 15 mg/kg/day orally given in 2 divided doses

and

praziquantel: children ≥4 years of age and adults: 50 mg/kg/day given in 3 divided doses

Plus – corticosteroid

Back
ACUTE
|
hepatic or thoracic disease
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Concurrent corticosteroid therapy can help to control oedema.

Primary options

prednisolone: children and adults: 1-2 mg/kg/day orally

OR

dexamethasone: children and adults: 0.2 to 0.4 mg/kg/day orally

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer