J Neurosurg 72:816-817, 1990
Albendazole therapy for subarachnoid and ventricular cysticercosis Case report OSCAR H. DEL BRUTTO, M.D., AND JULIO SOTELO, M.D. Research Division, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
u- Medical or surgical therapy for subarachnoid or ventricular cysticercosis is a controversial issue. The authors report a patient with cysticercus larvae in both ventricular and subarachnoid locations, who was successfully treated with albendazole. Thus, medical therapy has a role in the treatment of these forms of neurocysticercosis. K r u WORDS
albendazole
9 neurocysticercosis
A
LBENDAZOLEis an imidazole with activity against a broad range of intestinal and systemic infections by trematodes and cestodes. 2 Recent studies have demonstrated its efficacy in neurocysticercosis, where m o r e than 85% of p a r e n c h y m a l cysts disappear after a single course of therapy. 3'7 Currently, albendazole is considered superior to praziquantel for therapy of parenchymal brain cysticercosis and has replaced the latter as the drug of choice for this form of the disease. ~,6 There are no studies, however, confirming the efficacy of albendazole in subarachnoid or intraventricular cysticercosis. We report a patient with a mixed form of the disease including both intraventricular and subarachnoid cysticercus larvae. An adequate response to albendazole therapy was achieved. Case Report This 19-year-old w o m a n c o m p l a i n e d of intermittent headache and vomiting for l0 months. She had been treated for intestinal taeniasis during childhood. On admission to the hospital, her neurological examination revealed a symmetrical increase in muscle-stretch reflexes but was otherwise normal. Cerebrospinal fluid analysis showed 14 m o n o n u c l e a r cells/cu m m , with normal content of proteins and glucose. The enzymelinked i m m u n o s o r b e n t assay for detection o f anticysticercus antibodies was positive. Cranial computerized t o m o g r a p h y (CT) showed multiple nonenhancing cysts in the brain p a r e n c h y m a associated with subarachnoid 816
cysticercosis
~
chemotherapy
cysts in the quadrigeminal and ambient cisterns. In addition, a large cysticercus was seen in the occipital horn of the right lateral ventricle (Fig. 1 upper scans). A therapeutic course of albendazole was given at a daily dose of 15 mg/kg body weight for 8 days. 3 During the trial, the patient experienced transient exacerbation of headache, which remitted with c o m m o n analgesics. Three months following albendazole treatment, a new CT scan showed disappearance of the intracranial lesions, including the subarachnoid and intraventricular cysts (Fig. 1 lower scans). Clinically, the patient was asymptomatic and the neurological examination was normal. Discussion Differences on the CT scans obtained before and 3 months after the end of albendazole therapy showed the effectiveness of this drug for subarachnoid and intraventricular cysticerci in this patient. The treatment of cysticercosis in the subarachnoid space has been controversial? Some authors believe that surgical resection is the best approach to these lesions; 8 however, this report demonstrates that medical m a n a g e m e n t may be an equally effective yet less aggressive approach. For intraventricular cysticerci, indications for medical therapy must be individualized. We have recently recommended surgical resection particularly when the cyst is located in the fourth ventricle, since in most cases it is associated with increased intracranial pressure secondJ. Neurosurg. / Volume 7 2 / M a y , 1990
Subarachnoid and ventricular cysticercosis
FIG. 1. Upper." Contrast-enhanced computerized tomography (CT) scans obtained before albendazole therapy, showing multiple parenchymal cysts (left), a single intraventricular cyst in the occipital horn of right lateral ventricle (white arrow, center), and a clump of cysts within the quadrigeminal and ambient cisterns (arrowheads, right). Lower: Contrast-enhanced CT scans obtained 3 months after the end of therapy. Most lesions have disappeared, particularly those in the ventricular and subaraehnoid locations. a r y to o b s t r u c t i v e h y d r o c e p h a l u s . 4,5 Nevertheless, when the cyst is l o c a t e d in the lateral ventricles, as in the present case, a trial with a l b e n d a z o l e is r e c o m m e n d e d before a t t e m p t i n g surgical e x t i r p a t i o n . A c o n t r o l l e d trial for d r u g t r e a t m e n t o f s u b a r a c h n o i d a n d v e n t r i c u l a r cysticercosis is necessary. References
1. del Brutto OH, Sotelo J: Neurocysticercosis: an update. Rev Infect Dis 10:1075-1087, 1988 2. Editorial: Albendazole: worms and hydatid disease. Lancet 2:675-676, 1984 3. Escobedo F, Penagos P, Rodriguez J, et al: Albendazole therapy for neurocysticercosis. Arch Intern Med 147: 738-741, 1987 4. Sotelo J: Cysticercosis, in Johnson RT (ed): Current Therapy in Neurological Disease, ed 2. Philadelphia: BC Decker, 1987, pp 114-117
J. Neurosurg. / Volume 72~May, 1990
5. Sotelo J, del Brutto OH: Therapy of neurocysticercosis. Childs Nerv Syst 3:208-211, 1987 6. Sotelo J, Escobedo F, Penagos P: Albendazole versus praziquantel for the therapy for neurocysticercosis: a controlled trial. Arch Neurol 45:532-534, 1988 7. Sotelo J, Penagos P, Escobedo F, et al: Short course of albendazole therapy for neurocysticercosis. Arch Neurol 45:1130-1133, 1988 8. Torrealba G, DelVillar S, Tagle P, et al: Cysticercosis of the central nervous system: clinical and therapeutic considerations. J Neurol Neurosurg Psychiatry 47:784-790, 1984
Manuscript received August 3, 1989. Accepted in final form October 25, 1989. Address reprint requests to: Julio Sotelo, M.D., Research Division, Instituto Nacional de Neurologia y Neurocirugia Insurgentes Sur 3877, 14410 Mexico 22., D.F., Mexico.
817
Albendazole therapy for subarachnoid and ventricular cysticercosis Case report OSCAR H. DEL BRUTTO, M.D., AND JULIO SOTELO, M.D. Research Division, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
u- Medical or surgical therapy for subarachnoid or ventricular cysticercosis is a controversial issue. The authors report a patient with cysticercus larvae in both ventricular and subarachnoid locations, who was successfully treated with albendazole. Thus, medical therapy has a role in the treatment of these forms of neurocysticercosis. K r u WORDS
albendazole
9 neurocysticercosis
A
LBENDAZOLEis an imidazole with activity against a broad range of intestinal and systemic infections by trematodes and cestodes. 2 Recent studies have demonstrated its efficacy in neurocysticercosis, where m o r e than 85% of p a r e n c h y m a l cysts disappear after a single course of therapy. 3'7 Currently, albendazole is considered superior to praziquantel for therapy of parenchymal brain cysticercosis and has replaced the latter as the drug of choice for this form of the disease. ~,6 There are no studies, however, confirming the efficacy of albendazole in subarachnoid or intraventricular cysticercosis. We report a patient with a mixed form of the disease including both intraventricular and subarachnoid cysticercus larvae. An adequate response to albendazole therapy was achieved. Case Report This 19-year-old w o m a n c o m p l a i n e d of intermittent headache and vomiting for l0 months. She had been treated for intestinal taeniasis during childhood. On admission to the hospital, her neurological examination revealed a symmetrical increase in muscle-stretch reflexes but was otherwise normal. Cerebrospinal fluid analysis showed 14 m o n o n u c l e a r cells/cu m m , with normal content of proteins and glucose. The enzymelinked i m m u n o s o r b e n t assay for detection o f anticysticercus antibodies was positive. Cranial computerized t o m o g r a p h y (CT) showed multiple nonenhancing cysts in the brain p a r e n c h y m a associated with subarachnoid 816
cysticercosis
~
chemotherapy
cysts in the quadrigeminal and ambient cisterns. In addition, a large cysticercus was seen in the occipital horn of the right lateral ventricle (Fig. 1 upper scans). A therapeutic course of albendazole was given at a daily dose of 15 mg/kg body weight for 8 days. 3 During the trial, the patient experienced transient exacerbation of headache, which remitted with c o m m o n analgesics. Three months following albendazole treatment, a new CT scan showed disappearance of the intracranial lesions, including the subarachnoid and intraventricular cysts (Fig. 1 lower scans). Clinically, the patient was asymptomatic and the neurological examination was normal. Discussion Differences on the CT scans obtained before and 3 months after the end of albendazole therapy showed the effectiveness of this drug for subarachnoid and intraventricular cysticerci in this patient. The treatment of cysticercosis in the subarachnoid space has been controversial? Some authors believe that surgical resection is the best approach to these lesions; 8 however, this report demonstrates that medical m a n a g e m e n t may be an equally effective yet less aggressive approach. For intraventricular cysticerci, indications for medical therapy must be individualized. We have recently recommended surgical resection particularly when the cyst is located in the fourth ventricle, since in most cases it is associated with increased intracranial pressure secondJ. Neurosurg. / Volume 7 2 / M a y , 1990
Subarachnoid and ventricular cysticercosis
FIG. 1. Upper." Contrast-enhanced computerized tomography (CT) scans obtained before albendazole therapy, showing multiple parenchymal cysts (left), a single intraventricular cyst in the occipital horn of right lateral ventricle (white arrow, center), and a clump of cysts within the quadrigeminal and ambient cisterns (arrowheads, right). Lower: Contrast-enhanced CT scans obtained 3 months after the end of therapy. Most lesions have disappeared, particularly those in the ventricular and subaraehnoid locations. a r y to o b s t r u c t i v e h y d r o c e p h a l u s . 4,5 Nevertheless, when the cyst is l o c a t e d in the lateral ventricles, as in the present case, a trial with a l b e n d a z o l e is r e c o m m e n d e d before a t t e m p t i n g surgical e x t i r p a t i o n . A c o n t r o l l e d trial for d r u g t r e a t m e n t o f s u b a r a c h n o i d a n d v e n t r i c u l a r cysticercosis is necessary. References
1. del Brutto OH, Sotelo J: Neurocysticercosis: an update. Rev Infect Dis 10:1075-1087, 1988 2. Editorial: Albendazole: worms and hydatid disease. Lancet 2:675-676, 1984 3. Escobedo F, Penagos P, Rodriguez J, et al: Albendazole therapy for neurocysticercosis. Arch Intern Med 147: 738-741, 1987 4. Sotelo J: Cysticercosis, in Johnson RT (ed): Current Therapy in Neurological Disease, ed 2. Philadelphia: BC Decker, 1987, pp 114-117
J. Neurosurg. / Volume 72~May, 1990
5. Sotelo J, del Brutto OH: Therapy of neurocysticercosis. Childs Nerv Syst 3:208-211, 1987 6. Sotelo J, Escobedo F, Penagos P: Albendazole versus praziquantel for the therapy for neurocysticercosis: a controlled trial. Arch Neurol 45:532-534, 1988 7. Sotelo J, Penagos P, Escobedo F, et al: Short course of albendazole therapy for neurocysticercosis. Arch Neurol 45:1130-1133, 1988 8. Torrealba G, DelVillar S, Tagle P, et al: Cysticercosis of the central nervous system: clinical and therapeutic considerations. J Neurol Neurosurg Psychiatry 47:784-790, 1984
Manuscript received August 3, 1989. Accepted in final form October 25, 1989. Address reprint requests to: Julio Sotelo, M.D., Research Division, Instituto Nacional de Neurologia y Neurocirugia Insurgentes Sur 3877, 14410 Mexico 22., D.F., Mexico.
817
