Pediatric Neurocysticercosis

Does ensuring optimum vitamin D levels result in early resolution of neurocysticercosis?

BACKGROUND

Neurocysticercosis is a leading cause of acquired epilepsy. Calcified granulomas are known to cause seizure recurrence. Researchers have reported that vitamin D deficiency is associated with brain calcification and reduction in calcification occurs with vitamin D receptor agonist calcitriol through upregulation of SLC20A2. Based on these observations, a hypothesis was proposed that the occurrence of calcification could be reduced by optimizing vitamin D levels, resulting in early resolution of neurocysticercosis.

METHODOLOGY

A case-control (retrospective and prospective) study on 60 children with solitary intraparenchymal neurocysticercosis, 20 new cases prior to starting cysticidal therapy and other 40 resolved cases was carried out. Among new cases, children deficient in vitamin D were given megadose of vitamin D and vitamin D levels were rechecked after 30 days. Children having normal vitamin D were taken as cases and the deficient ones were taken as controls. Standard treatment for neurocysticercosis was given. Three monthly MRI scans were done. Outcome was evaluated as resolution/persistence of neurocysticercosis at 3, 6, 9 and 12 months.

STATISTICS AND RESULTS

Pearson chi square/Fisher's exact test was used along with Kaplan Meier and log rank test. Of 60 patients, at 6 months 3 cases and 4 controls (p value 0.43), at 9 months 2 cases and 6 controls (p value 0.037) and at 12 months 3 cases and 6 controls (p value 0.029) had complete resolution of NCC.

CONCLUSION

The results do not show that adequate vitamin D levels result in early resolution of neurocysticercosis.

An isolated subcutaneous paraspinal pseudo-tumor-more to it than meets the eye-a case report and review of literature

A 4-year-old male child presented to us with a paraspinal pseudo-tumor over the mid-back region with pain being his only symptom. On initial ultrasonography, it was presumed to be a nerve sheath tumor, but on an excision biopsy and histopathology, it proved to be a subcutaneous cysticercosis. Furthermore, an MRI of the brain showed a ring enhancing lesion with vasogenic edema, which confirmed the diagnosis of a neurologically symptomless neurocysticercosis. We treated the patient with albendazole and a short course of dexamethasone. There was complete resolution of the painful subcutaneous swelling, and the patient remained neurologically symptomless at all subsequent follow-ups. Resolution of the brain lesions was seen in the 6-month MRI follow-up. Although rare, orthopedic surgeons should consider the possibility of parasitic infections when dealing with small near-asymptomatic soft tissue paraspinal swellings of uncertain etiology. A thorough investigation in such cases can be lifesaving.

Neurocysticercosis-related Seizures: Imaging Biomarkers

Neurocysticercosis (NCC)-a parasitic CNS infection endemic to developing nations-has been called the leading global cause of acquired epilepsy yet remains understudied. It is currently unknown why a large proportion of patients develop recurrent seizures, often following the presentation of acute seizures. Furthermore, the presentation of NCC is heterogenous and the features that predispose to the development of an epileptogenic state remain uncertain. Perilesional factors (such as oedema and gliosis) have been implicated in NCC-related ictogenesis, but the effects of cystic factors, including lesion load and location, seem not to play a role in the development of habitual epilepsy. In addition, the cytotoxic consequences of the cyst's degenerative stages are varied and the majority of research, relying on retrospective data, lacks the necessary specificity to distinguish between acute symptomatic and unprovoked seizures. Previous research has established that epileptogenesis can be the consequence of abnormal network connectivity, and some imaging studies have suggested that a causative link may exist between NCC and aberrant network organisation. In wider epilepsy research, network approaches have been widely adopted; studies benefiting predominantly from the rich, multimodal data provided by advanced MRI methods are at the forefront of the field. Quantitative MRI approaches have the potential to elucidate the lesser-understood epileptogenic mechanisms of NCC. This review will summarise the current understanding of the relationship between NCC and epilepsy, with a focus on MRI methodologies. In addition, network neuroscience approaches with putative value will be highlighted, drawing from current imaging trends in epilepsy research.

Neurocysticercosis With Internal Carotid Artery and Middle Cerebral Artery Vasculitis and Stenosis

A seven-year-old female child presented with sub-acute onset headache, vomiting, and aphasia with right-sided upper motor neuron (UMN) type hemiparesis and ipsilateral UMN type facial nerve weakness. Her coagulation profile and thrombotic profile were normal. MRI brain with magnetic resonance angiography (MRA) detected neurocysticercosis causing secondary vasculitis and narrowing of supraclinoid left internal carotid artery (ICA) and middle cerebral artery (MCA). The patient was given aspirin along with steroids and albendazole. She improved gradually, and her hemiparesis and facial nerve palsy improved completely by three months and aphasia by four months.

Cortical Blindness Due to Neurocysticercosis in an Adolescent Patient

Neurocysticercosis (NCC) is a common cause of recent-onset seizures in both adults and children in tropical areas, especially when there is no other suggestion of another underlying neurological disorder. In addition, there have been reports of very rare cases of bilateral cortical blindness caused by this helminth in children. It is still unclear whether healthy adolescents with no pre-existing health problems could be vulnerable to developing such sequelae due to NCC. We report a case of a 14-year-old African boy from Nigeria with bilateral cortical blindness caused by NCC due to Taenia solium. According to the boy’s mother, symptoms began with headaches, vomiting, fatigue, visual loss, and fever (40.0 °C). Clinical investigations led to a diagnosis of cortical blindness and encephalitis due to NCC. Appropriate treatment was administered, and it resulted in the resolution of most symptoms, though the patient remained permanently blind.

Seizure Semiology, Location of Lesion on Neuroimaging, and Interictal Electroencephalographic (EEG) Abnormalities in Children With Single-Lesion Neurocysticercosis-Is There a Correlation?

BACKGROUND

Single-lesion neurocysticercosis provides a model of seizure genesis secondary to an acquired lesion. We aimed to study the correlation of seizure semiology with the location of the lesion and interictal electroencephalographic (EEG) abnormalities in children with single-lesion neurocysticercosis. Methods: Prospective, observational study in children with single-lesion neurocysticercosis and seizures. Seizure classification was done after an interview with the parent/onlooker and the child. Localization and lateralization of the lesion were done by neuroimaging. The EEG abnormalities were classified based on their morphology and location. Results: Ninety-two children (7.9 ± 2.4 years) were included. Focal-onset seizures were the commonest (n = 54; 58.6%) seizures. Majority of the lesions were located in the frontal (n = 43; 47%) and parietal cortex (n = 34; 37%). EEG showed focal slowing (n = 15; 53.6%) and epileptiform spikes/spike-wave complexes (n = 13; 46.4%). There was a perfect agreement of clinical semiology with imaging lateralization (K = 1.0) and moderate agreement with imaging localization (K = 0.4). There was no significant agreement of clinical localization with EEG slowing (K = 0.1) or sharps (K = 0). There was moderate agreement (K = 0.6) of EEG slowing and substantial agreement (K = 0.7) of EEG sharps with clinical lateralization. Focal EEG slowing had moderate (K = 0.5) agreement with imaging lateralization. Focal sharps/spikes had substantial (K = 0.7) agreement with imaging lateralization. The positive predictive value (PPV) of seizure semiology for lateralization and localization was 100% and 68%, respectively. PVV of focal sharps for lateralization and localization was 84% and 70%, respectively. PPV of focal slowing for lateralization and localization was 77% and 65%, respectively. Conclusion: Seizure semiology in single-lesion neurocysticercosis correlates very well with lateralization but not so well with localization of lesion on neuroimaging. Focal EEG abnormalities are seen in nearly one-third of children with single-lesion neurocysticercosis. EEG often predicts the side of the lesion but has poor localizing value.

Efficacy of Combination Therapy of Albendazole and Praziquantel vs Albendazole Monotherapy in Children With Persistent Neurocysticercosis: A Randomized Controlled Trial

AIM

To compare the efficacy of combined albendazole and praziquantel therapy vs albendazole monotherapy in a placebo-controlled, double-blinded, randomized trial in children with persisting neurocysticercosis.

METHODS

Children with persistent neurocysticercosis were randomized into 3 groups-albendazole (n = 19), albendazole and praziquantel (n = 21), and placebo (n = 20)-for 30 days and followed up at 3 and 6 months for resolution and recurrence of seizures.

RESULTS

Mean age of children was 9.3 ± 2.9 years (range 3-14). At baseline, the majority of lesions were ring-enhancing (70%), colloidal (97%), with scolex (68%) and perilesional-edema (45%), and located in the parietal (58%) lobe. One case each in albendazole and placebo groups had a recurrence of seizure in the first month of treatment. The majority (62%) of children in the combination therapy group showed complete resolution of the persisting lesion at the end of 6 months compared to the albendazole alone group (26.3%, P = .02). Percentage reduction in the lesion's mean area at 6 months was highest in the combination group compared with other groups (P = .006). Rate of calcification was identical in all 3 groups (10%). None of the patients required interruption of therapy.

CONCLUSION

Our study demonstrates the safety and efficacy of albendazole and praziquantel in combination for complete radiologic resolution in children with persistent neurocysticercosis when compared with albendazole monotherapy or placebo. The combination therapy did not result in increased seizure recurrence or adverse drug reaction compared with albendazole monotherapy.

Neurocysticercosis in Children

Neurocysticercosis is one of the most common parasitic infections in the central nervous system in children. The usual clinical manifestation is new-onset focal seizure. However, there are other multiple clinical manifestations, such as increased intracranial pressure, meningoencephalitis, spinal cord syndrome, and blindness. The diagnosis needs high index of suspicion with clinical history, physical examination, neuroimaging, and immunologic studies. Recent advances in neuroimaging and serology facilitate the accurate diagnosis. Management of neurocysticercosis should focus on critical symptoms first, such as the use of antiepileptic drugs and medical or surgical therapy for increased intracranial pressure.

Comparison of Long-Term Outcomes Between 7 Days and 28 Days Albendazole Monotherapy in the Treatment of Single-Lesion Neurocysticercosis in Children

OBJECTIVES

The objective was to compare the long-term clinical, radiological, and cognitive outcomes in children with single-lesion neurocysticercosis who received 7 or 28 days of albendazole therapy.

METHODOLOGY

This observational study conducted over 1 year included (1) consecutive children with single-lesion neurocysticercosis who received 7 or 28 days of albendazole therapy in the acute state and (2) completed follow-up for at least 5 years. Seizure recurrence, resolution of lesions, cognition (Malin's Intelligence Scale for Indian Children), behavior, and school performance (National Initiative for Children Healthcare Quality Vanderbilt Assessment Scale) were assessed.

RESULTS

Group A (albendazole for 7 days) comprised 55 children, and group B (albendazole for 28 days) included 48 children. The mean age at the time of diagnosis of neurocysticercosis was 6.6 ± 1.8 years; the mean age at the time of assessment for the study was 13.2 ± 1.2 years. Focal-onset seizures were the most common clinical presentation (58.3%). The majority of lesions were ring-shaped (92.3%) or colloidal (58.2%), with perilesional edema (89.3%). In the long-term follow-up, radiological resolution of the lesions was comparable in both groups. Complete resolution was seen in 52.7% receiving 7 days and 54.2% receiving 28 days albendazole. Seizures recurred in 20% receiving 7 days and 20.8% receiving 28 days albendazole. Overall, a low intelligence quotient (IQ < 70) was seen in 55.3% cases, "somewhat problematic" school performance in 12%, and behavioral abnormalities were present in 20% of the cases. The results were comparable between the 2 groups.

CONCLUSION

Seizure control, radiological resolution of lesion, school performance, cognitive and behavioral outcomes in the long term are comparable in children with single-lesion neurocysticercosis who have received albendazole cysticidal therapy for 7 days and 28 days. Recurrence of seizure is seen with both regimens in the long term, necessitating regular follow-up and discussion regarding the risk of recurrence before a withdrawal of anticonvulsant therapy.