Treatment of epilepsy in people with neurocysticercosis

Neurocysticercosis is a common infection of the brain caused by the larvae of the pork tapeworm, migrating to the brain. Seizure is the most common symptom, while some people may present with headache, vomiting or brain swelling. This review investigates the usefulness of antiepileptic drugs (AEDs) in preventing seizures in people who did not have seizures but presented with headache or brain oedema. We also examined the usefulness of the AEDS in people with neurocysticercosis with epilepsy in terms of choice of drug, dosage, duration of treatment, cost, side effects and the quality of life.

Four trials with a total of 466 participants (identified from a literature search in May 2015) were reviewed, focusing on the comparison of 'short duration' and 'long duration' of AEDs drugs in people with a single cerebral lesion. These trials compared various durations of AED therapy viz. six to 12 months as short duration and 12 to 24 months as long-duration therapy. No statistically significant benefit of one duration of AED over the other(six, 12 or 24 months) could be demonstrated. In people with calcified cysts, longer duration of therapy may be preferable.

All four included trials, enrolled people with a single brain lesion. The findings of our review cannot be extrapolated to people with multiple cysts or with cysts in unusual parts of the brain.

Authors' conclusions: 

Despite neurocysticercosis being the most common cause of epilepsy worldwide, there is currently no evidence available regarding the use of AEDs as prophylaxis for preventing seizures among people presenting with symptoms other than seizures. For those presenting with seizures, there is no reliable evidence regarding the duration of treatment required. There is therefore a need for large scale randomised controlled trials to address these questions.

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Background: 

Neurocysticercosis is the most common parasitic infection of the brain. Epilepsy is the commonest clinical presentation, though it may also present with headache, symptoms of raised intracranial tension, hydrocephalus and ocular symptoms depending upon the localisation of the parasitic cysts. Anthelmintic drugs, anti-oedema drugs, such as steroids and antiepileptic drugs (AEDs) form the mainstay of treatment.

Objectives: 

To assess the effects (benefits and harms) of AEDs for the primary and secondary prevention of seizures in people with neurocysticercosis.

Search strategy: 

We searched the Cochrane Epilepsy Group Specialized Register (5 May 2015), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library April 2015, Issue 4), MEDLINE (1946 to 5 May 2015), LILACS (Latin American and Caribbean Literature in Health Sciences, 5 May 2015), SCOPUS (1823 to 15 April 2014), ClinicalTrials.gov (7 May 2015), and the WHO International Clinical Trials Registry Platform ICTRP (7 May 2015). We also checked the references lists of identified studies, and contacted experts in the field and colleagues to search for additional studies and for information about ongoing studies.

Selection criteria: 

Randomised and quasi-randomised controlled trials.

The studies may be single blind, double blind or unblinded.

Data collection and analysis: 

One review author screened all citations for eligibility.Two review authors independently extracted data and evaluated each study for risk of bias.

Main results: 

We did not find any trials that investigated the role of AEDs in preventing seizures among people with neurocysticercosis, presenting with symptoms other than seizures.

We did not find any trials that evaluated evaluating individual AEDs in people with neurocysticercosis.

We found one trial, comparing two AEDs in people with solitary neurocysticercosis with seizures. However, we excluded this study from the review as it was of poor quality.

We found four trials that compared the efficacy of short term versus longer term AED treatment for people with solitary neurocysticercosis (identified on CT scan) presenting with seizures. In total, 466 people were enrolled. These studies compared various AED treatment durations, six, 12 and 24 months. The risk of seizure recurrence with six months treatment compared with 12 to 24 months treatment was not statistically significant (odds ratio (OR) 1.34, 95% confidence interval (CI) 0.73 to 2.47) (three studies n = 360, P 0.35). The risk of seizure recurrence with six to 12 months compared with 24 months treatment was not statistically significant (OR 1.36, 95% CI 0.72 to 2.57) (three studies, n = 385, P 0.34).

Two studies co-related seizure recurrence with CT findings and suggested that persistent and calcified lesions had a higher recurrence risk and suggest longer duration of treatment with AEDs. One study reported no side effects, while the rest did not comment on side effects of drugs. None of the studies addressed the quality of life of the participants.These studies had certain methodological deficiencies such as a small sample size and a possibility of bias due to lack of blinding, which affect the results of this review.

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