Neurocysticercosis¶

VERSION: 1.1 CREATED: February 2, 2026 REVISED: February 2, 2026 STATUS: Revised per checker/rebuilder pipeline (v1.1)

DIAGNOSIS: Neurocysticercosis

ICD-10: B69.0 (Cysticercosis of central nervous system), B69.1 (Cysticercosis of eye), B69.81 (Myositis in cysticercosis), B69.89 (Cysticercosis of other sites)

CPT CODES: 86682 (Cysticercosis antibody), 87015 (CSF concentration for infectious agents), 86235 (Nuclear antibody, extractable), 70553 (MRI brain with/without contrast), 70460 (CT head with contrast), 70450 (CT head without contrast), 95816 (EEG routine), 95819 (EEG with sleep), 95700-95720 (continuous EEG), 89051 (CSF cell count with differential), 84157 (CSF protein), 82945 (CSF glucose), 87205 (Gram stain), 96374 (IV push injection), 96365 (IV infusion), 61510 (craniotomy for excision), 62270 (lumbar puncture), 70551 (MRI brain without contrast), 77084 (MRI whole body screening), 93000 (ECG)

SYNONYMS: Neurocysticercosis, NCC, cerebral cysticercosis, brain cysticercosis, cysticercosis of the central nervous system, Taenia solium neurocysticercosis, pork tapeworm brain infection, parenchymal neurocysticercosis, racemose neurocysticercosis, ventricular cysticercosis, subarachnoid cysticercosis, spinal cysticercosis, calcified neurocysticercosis, cysticercal encephalitis

SCOPE: Diagnosis, staging, antiparasitic treatment, corticosteroid management, antiseizure medication selection, and follow-up of neurocysticercosis in adults. Covers all anatomic forms: parenchymal (vesicular, colloidal vesicular, granular nodular, calcified), ventricular (intraventricular), subarachnoid (racemose/basilar), and spinal neurocysticercosis. Includes Del Brutto diagnostic criteria, staging-based treatment approach, albendazole and praziquantel combination therapy, corticosteroid protocols, and surgical indications for hydrocephalus and intraventricular cysts. Excludes ocular cysticercosis (ophthalmology management), isolated subcutaneous cysticercosis without CNS involvement, and pediatric neurocysticercosis (dosing differences).

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (CPT 85025)	STAT	STAT	ROUTINE	STAT	Eosinophilia in 10-30% of NCC; baseline for monitoring corticosteroid and antiparasitic toxicity; leukocytosis indicates co-infection or cysticercal encephalitis	Eosinophilia (peripheral) in minority; normal WBC does NOT exclude NCC
CMP (BMP + LFTs) (CPT 80053)	STAT	STAT	ROUTINE	STAT	Hepatic function for albendazole metabolism (hepatotoxicity risk); renal function baseline; electrolytes for seizure management; glucose monitoring during corticosteroid use	Normal; monitor LFTs during albendazole course
CRP (C-reactive protein) (CPT 86140)	STAT	STAT	ROUTINE	STAT	Assess inflammatory response to cyst degeneration; elevated during colloidal stage (active inflammation); monitor treatment-related inflammation	Variable; elevated during colloidal vesicular stage; declining with treatment
ESR (erythrocyte sedimentation rate) (CPT 85652)	URGENT	ROUTINE	ROUTINE	URGENT	Nonspecific inflammatory marker; mildly elevated; useful to distinguish from other infectious etiologies	Normal or mildly elevated
Serum cysticercosis antibody (EITB/immunoblot) (CPT 86682)	URGENT	STAT	ROUTINE	STAT	Preferred serologic test — enzyme-linked immunoelectrotransfer blot (EITB) sensitivity 94-98% for >1 viable cyst, specificity ~100%; sensitivity drops to 50-70% for single calcified lesion; positive supports diagnosis per Del Brutto criteria	Positive (reactive to >=1 of 7 glycoprotein antigens); negative does NOT exclude NCC with single lesion or calcified disease
Serum cysticercosis ELISA (CPT 86682)	URGENT	STAT	ROUTINE	STAT	Screening test; sensitivity 65-87%; specificity 75-100%; less specific than EITB; cross-reacts with other cestodes; use as adjunct if EITB unavailable	Positive supports diagnosis; confirm with EITB if available
PT/INR, aPTT (CPT 85610+85730)	STAT	STAT	-	STAT	Coagulopathy assessment before LP or surgical intervention	Normal; correct if abnormal before procedures
Blood glucose / HbA1c (CPT 82947+83036)	STAT	STAT	ROUTINE	STAT	Baseline before corticosteroid therapy; diabetes screening (steroid-induced hyperglycemia common)	HbA1c <6.5%; glucose <180 mg/dL during steroid use
Pregnancy test (urine/serum hCG) (CPT 81025)	STAT	STAT	ROUTINE	-	Albendazole is teratogenic (Category C); praziquantel is Category B; exclude pregnancy before initiating antiparasitic therapy	Negative required before antiparasitic therapy
Lactate (CPT 83605)	STAT	-	-	STAT	If sepsis or meningoencephalitis suspected; cysticercal encephalitis with systemic inflammatory response	<2 mmol/L

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Serum antigen detection (Ag-ELISA) for T. solium (CPT 86682)	-	ROUTINE	ROUTINE	ROUTINE	Detects circulating parasite antigen; positive indicates viable (living) cysts; useful for monitoring treatment response (declining antigen = cyst death); sensitivity 65-90% for multiple viable cysts	Positive indicates viable cysts; declining titer monitors treatment response; negative in single cyst or calcified disease
HIV 1/2 antigen/antibody (CPT 87389)	-	ROUTINE	ROUTINE	-	Immunocompromise assessment; HIV alters NCC presentation and treatment response; concurrent opportunistic infections complicate management	Negative; if positive: obtain CD4 count; affects treatment duration
Stool ova and parasites x3 (CPT 87177)	-	ROUTINE	ROUTINE	-	Identify intestinal Taenia solium carriage (taeniasis); present in 5-15% of NCC patients; treatment of intestinal tapeworm prevents ongoing autoinfection and community transmission	Negative; if positive: treat with niclosamide or praziquantel (single dose) for intestinal tapeworm
Taenia solium stool antigen (coproantigen) (CPT 87177)	-	ROUTINE	ROUTINE	-	More sensitive than microscopic stool O&P for detecting intestinal Taenia solium; important for public health (household contacts)	Negative; if positive: treat intestinal taeniasis
Serum sodium (CPT 84295)	STAT	ROUTINE	-	STAT	SIADH assessment (intracranial pathology); hyponatremia from cerebral salt wasting; important with corticosteroid use and ICP management	135-145 mEq/L
Serum osmolality (CPT 83930)	URGENT	ROUTINE	-	URGENT	SIADH vs. cerebral salt wasting differentiation; relevant if on mannitol or hypertonic saline for elevated ICP	280-295 mOsm/kg
Strongyloides serology (CPT 86682)	-	ROUTINE	ROUTINE	-	Screen before high-dose corticosteroids; Strongyloides hyperinfection syndrome is fatal during immunosuppression; endemic area overlap with NCC	Negative required before initiating prolonged corticosteroids; if positive: treat with ivermectin before steroids
LFTs (ALT, AST, bilirubin, alkaline phosphatase) (CPT 80076)	-	ROUTINE	ROUTINE	ROUTINE	Albendazole causes hepatotoxicity in 2-5%; monitor during and after treatment; praziquantel primarily hepatically metabolized	Normal; if ALT/AST >3x ULN: hold albendazole
Antiepileptic drug levels (CPT 80201-80299)	-	ROUTINE	ROUTINE	ROUTINE	If on concurrent AEDs; praziquantel levels reduced by 50-75% with enzyme-inducing AEDs (carbamazepine, phenytoin); albendazole sulfoxide levels reduced by dexamethasone co-administration	Therapeutic range for specific AED

1C. Rare/Specialized (Refractory or Atypical)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CSF cysticercosis antibody (EITB) (CPT 86682)	-	ROUTINE	-	ROUTINE	Higher sensitivity than serum for subarachnoid/ventricular NCC; important when serum EITB negative but clinical suspicion high; CSF detects intrathecal antibody production	Positive; intrathecal synthesis supports CNS NCC
CSF cysticercus antigen (Ag-ELISA) (CPT 86682)	-	ROUTINE	-	ROUTINE	Detects viable cysts in CSF; especially useful in subarachnoid (racemose) and ventricular NCC where serum tests less reliable; monitor treatment response	Positive indicates viable cysts in CSF space
CSF Taenia solium PCR (CPT 87798)	-	EXT	-	EXT	Molecular confirmation when serology equivocal; identifies species-specific DNA in CSF; limited availability	Positive; confirms T. solium DNA
Histopathology of excised cyst	-	ROUTINE	-	-	Gold standard per Del Brutto absolute criteria; identifies scolex, cyst wall, hooklets; confirms T. solium species; from surgical excision or endoscopic removal	Parasitic structures: scolex with rostellar hooklets, cyst wall with tegument and subtegumental cells
Brain biopsy / cyst excision with pathology	-	EXT	-	-	When diagnosis uncertain despite imaging and serology; to differentiate from tumor, abscess, or other granulomatous disease	Cysticercus larva identified; parasitic elements within cyst; surrounding inflammatory tissue
QuantiFERON-TB Gold (CPT 86480)	-	ROUTINE	ROUTINE	-	Tuberculoma is key differential for ring-enhancing lesions in endemic areas with geographic overlap; rule out concurrent TB meningitis	Negative
Toxoplasma IgG antibody (CPT 86777)	-	ROUTINE	ROUTINE	ROUTINE	Differential diagnosis in immunocompromised patients; ring-enhancing lesions; especially if HIV-positive	Negative; if positive with HIV: evaluate for concurrent toxoplasmosis
Serum galactomannan (CPT 87305)	-	EXT	-	EXT	If immunocompromised with atypical enhancement pattern; fungal abscess in differential	Negative (<0.5 index)
Complement levels (CH50, C3, C4)	-	EXT	EXT	-	Subarachnoid NCC triggers complement-mediated vasculitis; monitor if vasculitis suspected	Normal or decreased

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT head without contrast (CPT 70450)	STAT	STAT	-	STAT	Immediate; first-line in ED for seizure, headache; best for detecting calcified lesions which MRI misses	Calcified granulomas (most common finding in endemic areas); single or multiple calcified nodules; perilesional edema around calcified lesion (seizure trigger); hydrocephalus; parenchymal cysts	Pregnancy (relative; benefit outweighs risk in acute setting)
CT head with contrast (CPT 70460)	STAT	STAT	-	STAT	Immediate if non-contrast shows edema or cysts; ring enhancement identifies colloidal/granular stage	Ring-enhancing lesion (colloidal vesicular stage); disc enhancement (granular nodular stage); calcified nodules with or without surrounding edema; scolex visible as eccentric hyperdense dot within cyst	Contrast allergy (pre-medicate); renal impairment
MRI brain with and without contrast (CPT 70553)	STAT	STAT	ROUTINE	STAT	Within 24h if CT suspicious; gold standard for NCC staging, cyst counting, scolex visualization, and identifying ventricular/subarachnoid disease	Vesicular stage: CSF-intensity cyst with scolex (bright dot on FLAIR); Colloidal stage: ring enhancement, perilesional edema, bright cyst fluid on FLAIR; Granular nodular: nodular/ring enhancement, decreasing edema; Calcified: T2 hypointense, perilesional edema possible; Ventricular: mobile cyst within ventricle; Subarachnoid/racemose: multilobulated grape-like cysts in cisterns	Pacemaker; metallic implants; claustrophobia (sedate)
Chest X-ray (CPT 71046)	-	ROUTINE	ROUTINE	-	Within first 24h if admitted	Soft tissue calcifications (subcutaneous/muscular cysticerci, "cigar-shaped" calcifications); pulmonary findings; baseline	None significant

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI spine with and without contrast (CPT 72156)	-	ROUTINE	ROUTINE	-	If spinal symptoms (radiculopathy, myelopathy); within 48-72h	Intradural extramedullary or intramedullary cysticercus; spinal leptomeningeal enhancement; arachnoiditis; subarachnoid cysts along spinal cord	Same as MRI brain
CT cisternography (CPT 70450)	-	EXT	-	-	If subarachnoid NCC suspected but standard imaging equivocal; enhances visualization of cisternal cysts	Racemose cysts in basal cisterns; filling defects in subarachnoid space	Intrathecal contrast allergy; elevated ICP
Plain radiographs of thighs and shoulders (CPT 73552+73030)	-	ROUTINE	ROUTINE	-	Screening for disseminated cysticercosis; confirm systemic disease	Cigar-shaped calcifications in muscles (pathognomonic for disseminated cysticercosis); supports NCC diagnosis per Del Brutto minor criteria	None
EEG (routine) (CPT 95816)	-	ROUTINE	ROUTINE	-	If seizure at presentation; baseline for patients starting AED therapy; evaluate for subclinical seizure activity	Focal epileptiform discharges corresponding to cyst location; generalized abnormalities; background slowing	None significant
Continuous EEG (cEEG) (CPT 95700)	-	URGENT	-	STAT	If altered mental status; concern for cysticercal encephalitis with non-convulsive seizures; refractory seizures	Seizure activity; non-convulsive status epilepticus	None significant
Echocardiogram (TTE) (CPT 93306)	-	EXT	EXT	-	If cardiac cysticercosis suspected (rare); disseminated disease	Intracardiac cysts (rare)	None significant
CT orbits (CPT 70480)	-	ROUTINE	ROUTINE	-	If visual symptoms or concern for ocular cysticercosis; rule out ocular cysts before starting antiparasitic therapy (treatment causes cyst inflammation that destroys vision)	Intraocular or periorbital cysticercus; retinal cyst; subretinal cyst	Contrast allergy
Ophthalmologic examination (fundoscopy)	URGENT	STAT	ROUTINE	-	MANDATORY before starting antiparasitic treatment; ocular cysticercosis is a contraindication to antiparasitic drugs; treatment-induced inflammation causes blindness	Intraocular cyst (vitreous, retinal, subretinal); papilledema (elevated ICP)	None
ECG (12-lead) (CPT 93000)	URGENT	ROUTINE	-	URGENT	Baseline; QTc assessment before medications; cardiac cysticercosis screen in disseminated disease	Normal; QTc prolongation risk with some AEDs	None

2C. Rare/Specialized¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
FIESTA/CISS MRI sequences (3D heavily T2-weighted)	-	ROUTINE	ROUTINE	-	For intraventricular cyst visualization; superior to standard MRI for small ventricular and subarachnoid cysts	Intraventricular cyst outline clearly delineated; scolex visible; cyst relationship to ventricular walls and foramina	Same as MRI brain
Phase-contrast cine MRI	-	EXT	-	-	If mobile intraventricular cyst suspected (ball-valve hydrocephalus); demonstrates cyst mobility with CSF flow	Mobile cyst causing intermittent foramen obstruction	Same as MRI brain
PET-CT brain (CPT 78816)	-	-	EXT	-	If diagnosis uncertain despite standard workup; differentiate from neoplasm	Cysticercal lesion: minimal FDG uptake (peripheral inflammatory ring); neoplasm: diffuse uptake	Pregnancy; uncontrolled diabetes
ICP monitoring (EVD)	-	-	-	URGENT	Acute hydrocephalus from ventricular cyst obstruction; declining consciousness from cysticercal encephalitis	ICP <22 mmHg; CPP >60 mmHg	Coagulopathy (correct first)
Neuroendoscopy (diagnostic/therapeutic)	-	URGENT	-	-	Intraventricular cyst removal; direct visualization and excision; avoids open craniotomy	Cyst visualized and excised intact; scolex identified; cyst-free ventricle post-procedure	Coagulopathy; inaccessible cyst location

LUMBAR PUNCTURE¶

Indication: Recommended when subarachnoid or ventricular NCC suspected; useful for CSF cysticercosis antibody/antigen testing; monitor treatment response in extraparenchymal disease. Generally NOT needed for isolated parenchymal calcified lesions.

Timing: URGENT if meningitis or elevated ICP suspected; ROUTINE for diagnostic workup of suspected subarachnoid/ventricular NCC.

Volume Required: 10-15 mL (standard diagnostic; additional for cysticercosis antibody and antigen testing)

Study	ED	HOSP	OPD	ICU	Rationale	Target Finding
Opening pressure (CPT 89050)	URGENT	ROUTINE	ROUTINE	URGENT	Elevated ICP common in ventricular and subarachnoid NCC; hydrocephalus assessment; baseline for monitoring	Normal 10-20 cm H2O; elevated in 50% of NCC with active inflammation or hydrocephalus
Cell count with differential (tubes 1 and 4) (CPT 89051)	URGENT	ROUTINE	ROUTINE	URGENT	CSF pleocytosis with lymphocytic/eosinophilic predominance; eosinophils (>5%) highly suggestive of parasitic infection; mononuclear predominance in chronic disease	WBC 5-500; CSF eosinophilia (>5%) strongly supports parasitic etiology; lymphocytic predominance common; polymorphonuclear in acute cyst rupture
Protein (CPT 84157)	URGENT	ROUTINE	ROUTINE	URGENT	Elevated in active inflammation and subarachnoid disease; markedly elevated in racemose NCC and arachnoiditis	Mildly to moderately elevated (50-300 mg/dL); markedly elevated (>200) in subarachnoid/racemose NCC
Glucose with paired serum (CPT 82945)	URGENT	ROUTINE	ROUTINE	URGENT	Low glucose indicates chronic meningitis (subarachnoid NCC, TB meningitis, fungal); usually normal in parenchymal NCC	Normal in parenchymal NCC; low (CSF/serum ratio <0.5) in subarachnoid NCC and chronic cysticercal meningitis
CSF cysticercosis antibody (EITB) (CPT 86682)	-	ROUTINE	ROUTINE	ROUTINE	Higher sensitivity than serum for subarachnoid and ventricular NCC; intrathecal antibody synthesis	Positive; supports active CNS cysticercosis
CSF cysticercosis antigen (Ag-ELISA) (CPT 86682)	-	ROUTINE	ROUTINE	ROUTINE	Detects viable cysts in CSF; serial monitoring of treatment response in extraparenchymal disease; declining antigen = successful treatment	Positive indicates viable cysts; serial decline with treatment
Gram stain and bacterial culture (CPT 87205+87070)	URGENT	ROUTINE	-	URGENT	Rule out bacterial meningitis as concurrent or alternative diagnosis	Negative
AFB smear and culture (CPT 87116)	-	ROUTINE	ROUTINE	ROUTINE	Rule out TB meningitis (key differential in endemic areas with overlapping epidemiology)	Negative
Fungal culture (CPT 87102)	-	ROUTINE	-	ROUTINE	Rule out fungal meningitis (Coccidioides, Histoplasma, Cryptococcus) if immunocompromised or endemic area	Negative
Cytology (CPT 88108)	-	ROUTINE	-	-	Rule out leptomeningeal carcinomatosis if atypical presentation or subarachnoid enhancement	No malignant cells

Special Handling: CSF cysticercosis antibody and antigen testing are specialized assays; send to reference laboratory (CDC or designated centers). Eosinophilia in CSF (>5% eosinophils) is highly suggestive of parasitic CNS infection. Serial CSF antigen monitoring useful for subarachnoid/ventricular NCC treatment response.

Contraindications: Obstructive hydrocephalus (risk of herniation); large space-occupying cyst with mass effect; obtain imaging BEFORE LP. If hydrocephalus present, place EVD first.

3. TREATMENT¶

CRITICAL: TREATMENT APPROACH¶

Neurocysticercosis treatment is STAGING-DEPENDENT. Not all NCC requires antiparasitic therapy. Treatment varies dramatically based on cyst viability, location, number, and host inflammatory response.

MANDATORY PRE-TREATMENT STEPS: 1. Ophthalmologic exam to rule out ocular cysticercosis (antiparasitic drugs cause intraocular inflammation leading to vision loss) 2. Brain imaging to stage disease and count cysts 3. Assess for hydrocephalus (treat hydrocephalus BEFORE antiparasitic therapy) 4. Start corticosteroids BEFORE or WITH antiparasitic drugs (prevent treatment-induced inflammation) 5. Start antiseizure medication if seizures present

STAGING-BASED APPROACH:

Stage	Imaging Appearance	Treatment
Vesicular (viable cyst)	CSF-intensity cyst with scolex; no enhancement; minimal edema	Antiparasitic therapy + corticosteroids
Colloidal vesicular (degenerating)	Ring-enhancing cyst; perilesional edema; bright cyst fluid on FLAIR	Antiparasitic therapy + corticosteroids
Granular nodular (involuting)	Nodular enhancement; shrinking lesion; decreasing edema	Antiparasitic therapy for residual viable elements; corticosteroids for edema
Calcified (inactive)	Calcified nodule; no enhancement (unless perilesional edema)	NO antiparasitic therapy; AEDs for seizures; corticosteroids only if perilesional edema
Ventricular	Cyst within ventricle; hydrocephalus	Surgical removal (endoscopic preferred) followed by antiparasitic therapy; treat hydrocephalus first
Subarachnoid (racemose)	Multilobulated cysts in cisterns; hydrocephalus; arachnoiditis	Prolonged antiparasitic + high-dose corticosteroids; VP shunt if hydrocephalus
Spinal	Intradural cyst; leptomeningeal enhancement	Surgical excision if accessible; antiparasitic + corticosteroids
Cysticercal encephalitis	Massive edema; diffuse viable cysts; elevated ICP	NO antiparasitic initially (worsens edema); corticosteroids + ICP management first; antiparasitic only after edema controlled

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Dexamethasone (CPT 96374)	IV	Pre-treatment corticosteroid BEFORE antiparasitic therapy; reduces treatment-induced inflammation from cyst degeneration; essential for cysticercal encephalitis; subarachnoid NCC with arachnoiditis	0.15 mg/kg :: IV :: q6h :: 0.15 mg/kg IV q6h (typically 4-8 mg q6h); start 1-2 days BEFORE antiparasitic drugs; taper over 2-4 weeks based on clinical response; longer courses for subarachnoid NCC; dexamethasone increases albendazole sulfoxide levels by 50%	Active untreated fungal/bacterial infection; uncontrolled diabetes (relative); GI bleed (relative)	Glucose q6h during IV therapy; GI prophylaxis; blood pressure; mood changes; taper schedule; infection signs	STAT	STAT	-	STAT
Levetiracetam (seizure management) (CPT 96374)	IV/PO	First-line antiseizure medication for NCC-related seizures; no hepatic enzyme induction (avoids reducing praziquantel levels); seizures occur in 70-90% of parenchymal NCC	1000 mg :: IV :: load then 500-1500 mg BID :: 1000 mg IV load, then 500-1000 mg IV/PO BID; titrate by 500 mg/day every 2 weeks to 1500 mg BID if seizures persist; max 3000 mg/day; does NOT interact with antiparasitic drugs	Severe renal impairment (dose adjust CrCl <30); behavioral side effects	Renal function; behavioral/mood changes (irritability, depression); CBC	STAT	STAT	ROUTINE	STAT
Mannitol 20% (CPT 96365)	IV	Elevated ICP from cysticercal encephalitis, large perilesional edema, or obstructive hydrocephalus; bridge to definitive treatment	1 g/kg :: IV :: bolus then 0.25-0.5 g/kg q4-6h :: 1-1.5 g/kg IV bolus over 20 min; then 0.25-0.5 g/kg q4-6h PRN for ICP >22; hold if serum osm >320	Anuria; severe dehydration; active intracranial bleeding	Serum osmolality (<320 mOsm/kg); osmolar gap; renal function; serum Na; I/O	STAT	URGENT	-	STAT
Hypertonic saline 23.4%	IV	Acute herniation from massive cerebral edema in cysticercal encephalitis; more sustained ICP reduction than mannitol	30 mL :: IV :: once over 10-20 min via central line :: 30 mL via central line over 10-20 min; target Na 145-155 mEq/L; repeat PRN	No central access (causes tissue necrosis peripherally)	Serum Na q4-6h; osmolality; central line access confirmed	STAT	URGENT	-	STAT
Lorazepam (seizure rescue)	IV	Active seizure in NCC; breakthrough seizure during antiparasitic treatment	4 mg :: IV :: push PRN seizure :: 0.1 mg/kg IV (max 4 mg) over 2 min; repeat x1 in 5 min if seizure continues; max 8 mg total	Respiratory depression; severe hypotension	Respiratory rate; SpO2; blood pressure; airway equipment at bedside	STAT	STAT	-	STAT
IV normal saline	IV	Maintenance fluids; avoid hypotonic solutions which worsen cerebral edema; euvolemia during corticosteroid therapy	0.9% NaCl :: IV :: continuous at 75-125 mL/h :: Isotonic fluids only; avoid D5W and half-normal saline; maintain euvolemia	Volume overload; CHF	I/O; electrolytes daily; serum Na	STAT	STAT	-	STAT

3B. Symptomatic Treatments¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	PO/IV	Headache management; fever control; avoid NSAIDs if concern for GI bleed during corticosteroid therapy	1000 mg :: PO :: q6h PRN :: 650-1000 mg PO/IV q6h; max 4 g/day; IV route if unable to take PO	Severe hepatic disease (caution with concurrent albendazole hepatotoxicity)	Temperature; LFTs (especially with concurrent albendazole)	STAT	STAT	ROUTINE	STAT
Ondansetron	IV/PO	Nausea and vomiting (common with elevated ICP and antiparasitic therapy; albendazole commonly causes nausea)	4 mg :: IV :: q6h PRN :: 4 mg IV/PO q6h PRN nausea; max 16 mg/day	QT prolongation; severe hepatic impairment (max 8 mg/day)	QTc if risk factors; hepatic function	STAT	ROUTINE	ROUTINE	STAT
Pantoprazole	IV/PO	GI prophylaxis during corticosteroid therapy; stress ulcer prevention in ICU; steroid-induced gastropathy prevention	40 mg :: IV :: daily :: 40 mg IV/PO daily; discontinue when steroids stopped and no longer in ICU	Long-term use risks (C. diff, hypomagnesemia); only while on steroids	GI symptoms; discontinue when steroids tapered	-	ROUTINE	ROUTINE	ROUTINE
Enoxaparin	SC	DVT prophylaxis; prolonged hospitalization and immobilization; steroid use increases VTE risk	40 mg :: SC :: daily :: 40 mg SC daily; start 24h post-surgery if no active bleeding; hold if upcoming surgery	Active intracranial bleeding; recent craniotomy (<24h); coagulopathy; platelets <50K	Platelets q3 days (HIT monitoring); coagulation panel	-	ROUTINE	-	ROUTINE
Pneumatic compression devices	Mechanical	DVT prophylaxis; apply on admission; use in conjunction with pharmacologic prophylaxis when safe	N/A :: Mechanical :: continuous :: Bilateral sequential compression devices; apply on admission; continue until fully ambulatory	Acute DVT in lower extremity; severe peripheral vascular disease	Skin integrity; proper fit; compliance	STAT	STAT	-	STAT
Fosphenytoin (seizure rescue second-line)	IV	Refractory seizure not responding to levetiracetam; status epilepticus; NOTE: phenytoin/fosphenytoin is enzyme-inducing and reduces praziquantel levels by 50%	20 mg PE/kg :: IV :: load then 100 mg PE q8h :: 20 mg PE/kg IV at 150 mg PE/min; maintenance 100 mg PE q8h; target free phenytoin level 1-2 mcg/mL	Bradycardia; second/third-degree heart block; hypotension; reduces praziquantel levels	Continuous telemetry during load; free phenytoin level; LFTs; drug interactions with antiparasitic agents	STAT	STAT	-	STAT
Lacosamide	IV/PO	Second-line AED for NCC-related seizures; no enzyme induction (preferred over carbamazepine/phenytoin which reduce praziquantel levels)	200 mg :: IV :: load then 100-200 mg BID :: 200 mg IV load, then 100-200 mg PO BID; max 400 mg/day; no significant drug interactions with antiparasitic agents	PR prolongation; second/third-degree AV block; severe hepatic impairment	ECG (PR interval); LFTs; cardiac rhythm	-	STAT	ROUTINE	STAT

3C. Second-line/Refractory — Antiparasitic Therapy¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Albendazole	PO	First-line antiparasitic for viable parenchymal NCC (vesicular and colloidal stages); 1-2 viable cysts: albendazole monotherapy x 7-14 days; >2 viable cysts: combine with praziquantel; subarachnoid/racemose NCC: prolonged courses (months); take with fatty meal (increases absorption 5-fold)	15 mg/kg/day :: PO :: divided BID (max 800 mg/day) :: 15 mg/kg/day PO divided BID (standard max 400 mg BID = 800 mg/day; up to 600 mg BID = 1200 mg/day for subarachnoid NCC or heavy cyst burden per ID specialist guidance); take with fatty meal; duration: 7-14 days for 1-2 parenchymal cysts; 10-14 days for >2 cysts (with praziquantel); weeks to months for subarachnoid NCC	Ocular cysticercosis (ABSOLUTE — causes vision loss); pregnancy (teratogenic); severe hepatic disease; cysticercal encephalitis with uncontrolled edema (treat edema first)	LFTs at baseline, day 7, day 14, then biweekly; CBC q2 weeks (leukopenia, thrombocytopenia); clinical response; repeat imaging at 3-6 months	-	STAT	ROUTINE	-
Praziquantel	PO	Combined with albendazole for >2 viable parenchymal cysts (combination more effective than either alone per RCTs); single agent if albendazole intolerance; NOTE: levels reduced 50-75% by enzyme-inducing AEDs (carbamazepine, phenytoin) and by dexamethasone — increase dose or use cimetidine to boost levels	50 mg/kg/day :: PO :: divided TID x 10-14 days :: 50 mg/kg/day PO divided TID; take with fatty meal; combine with albendazole for >2 viable cysts; duration 10-14 days for parenchymal NCC; if on enzyme-inducing AEDs: increase dose to 100 mg/kg/day or add cimetidine 400 mg TID to inhibit metabolism	Ocular cysticercosis (ABSOLUTE); pregnancy (Category B but avoid during treatment); concurrent rifampin (reduces levels markedly); cysticercal encephalitis with uncontrolled edema	LFTs; clinical response; drug interactions (enzyme-inducing AEDs reduce levels by 50-75%); repeat imaging at 3-6 months	-	STAT	ROUTINE	-
Cimetidine (praziquantel booster)	PO	Inhibits CYP3A4 metabolism of praziquantel; increases praziquantel bioavailability 2-fold; essential when enzyme-inducing AEDs cannot be avoided	400 mg :: PO :: TID :: 400 mg PO TID; start 1-2 days before praziquantel; continue throughout praziquantel course	Renal impairment (dose adjust); drug interactions (inhibits CYP3A4)	Drug interactions; renal function	-	ROUTINE	ROUTINE	-
Prednisone (oral steroid taper)	PO	Transition from IV dexamethasone; prolonged steroid course for subarachnoid NCC; maintenance anti-inflammatory therapy during outpatient antiparasitic treatment	1 mg/kg :: PO :: daily :: 1 mg/kg/day PO (max 60 mg) then taper over 2-4 weeks for parenchymal NCC; for subarachnoid/racemose NCC: prolonged taper over months (years for chronic arachnoiditis)	Active infections; uncontrolled diabetes; GI ulcer; osteoporosis (relative for prolonged use)	Glucose; blood pressure; weight; bone density if prolonged use (>3 months); mood changes; infection signs; adrenal suppression	-	ROUTINE	ROUTINE	-
Methotrexate (steroid-sparing agent)	PO	Steroid-sparing agent for subarachnoid/racemose NCC requiring prolonged anti-inflammatory therapy (months to years); allows corticosteroid taper while maintaining anti-inflammatory effect	7.5-20 mg :: PO :: weekly :: Start 7.5 mg PO weekly; titrate to 15-20 mg weekly as tolerated; supplement with folic acid 1 mg daily (except on MTX day); onset of effect 4-6 weeks	Pregnancy (teratogenic); severe hepatic/renal impairment; immunodeficiency; bone marrow suppression; interstitial lung disease	CBC with differential monthly; LFTs monthly; renal function monthly; folic acid compliance; pulmonary symptoms	-	-	ROUTINE	-
Niclosamide	PO	Treatment of intestinal Taenia solium (taeniasis) to eliminate tapeworm and prevent ongoing autoinfection and community transmission	2 g :: PO :: single dose :: 2 g PO as single dose (chew thoroughly then swallow with water); take on empty stomach; purge 2h after to expel worm segments	Allergy; none significant	Stool follow-up at 1 and 3 months post-treatment to confirm eradication; household contacts screened	-	ROUTINE	ROUTINE	-

3D. Surgical Management (Disease-Modifying)¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Neuroendoscopic cyst removal	Surgical	Preferred approach for intraventricular cysticercosis; direct visualization and excision of cyst; avoids open craniotomy; lateral and third ventricle cysts most amenable; fourth ventricle more challenging	Single procedure; cyst removed intact when possible; combined with ventriculostomy if hydrocephalus	MRI with FIESTA/CISS sequences to localize cyst; coagulation panel (INR <1.5, platelets >100K); neurosurgery consultation; anesthesia clearance	Coagulopathy (correct first); inaccessible cyst location; severe inflammation precluding safe dissection	Post-procedure MRI within 24-48h; neurologic exam q1h x 6h then q2h; signs of hemorrhage; CSF leak; hydrocephalus resolution	-	STAT	-	STAT
VP shunt placement	Surgical	Obstructive hydrocephalus from subarachnoid (racemose) NCC or chronic arachnoiditis; communicating hydrocephalus from chronic meningitis; when endoscopic cyst removal not feasible or hydrocephalus persists after cyst removal	Permanent CSF diversion; programmable valve preferred	CT/MRI confirming hydrocephalus; coagulation panel; neurosurgery consultation; assess for shunt infection risk	Active CNS infection (relative; requires simultaneous treatment); coagulopathy	Shunt function (clinical and imaging); shunt infection surveillance; ventricular size on follow-up imaging; signs of over-drainage or under-drainage	-	STAT	-	STAT
Endoscopic third ventriculostomy (ETV)	Surgical	Alternative to VP shunt for obstructive hydrocephalus; avoids shunt dependency; combine with endoscopic cyst removal when feasible	Single procedure; creates CSF pathway bypassing obstruction	MRI anatomy assessment; coagulation panel; neurosurgery	Communicating hydrocephalus (ETV less effective); basilar artery adherent to floor of third ventricle	Post-procedure imaging; neurologic exam; ICP monitoring if EVD placed	-	STAT	-	STAT
Craniotomy with cyst excision	Surgical	Large parenchymal cyst with significant mass effect not amenable to medical therapy; giant subarachnoid (racemose) cyst; fourth ventricle cyst not amenable to endoscopic removal; diagnostic uncertainty requiring tissue	Complete excision of cyst with capsule when feasible	CT/MRI navigation imaging; coagulation panel; type and crossmatch; corticosteroid pre-treatment; neurosurgery and anesthesia	Multiple deep cysts; eloquent cortex (relative); severe comorbidities precluding general anesthesia	Post-operative neurologic exam q1h x 12h then q2h; CT at 24h; wound care; ICP if EVD; seizure monitoring	-	STAT	-	STAT
External ventricular drain (EVD)	Surgical	Acute obstructive hydrocephalus from ventricular cyst; cysticercal encephalitis with elevated ICP; bridge to definitive treatment	Continuous or intermittent CSF drainage; target ICP <22 mmHg; target CPP >60 mmHg	Coagulation panel; neurosurgery; CT confirming hydrocephalus	Severe coagulopathy (correct first)	ICP continuous; CSF output hourly; CSF culture daily; EVD site care; neurologic exam q1h	-	-	-	STAT

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Infectious disease consultation for antiparasitic regimen selection, dosing optimization, drug interactions, and treatment duration guidance	STAT	STAT	ROUTINE	STAT
Neurosurgery consultation for ventricular cysts, hydrocephalus management (VP shunt, ETV, EVD), large cysts with mass effect, and diagnostic tissue sampling	STAT	STAT	-	STAT
Neurology consultation for seizure management, AED selection (avoiding enzyme-inducing agents), EEG interpretation, and long-term epilepsy management	URGENT	URGENT	ROUTINE	STAT
Ophthalmology consultation MANDATORY before initiating antiparasitic therapy to rule out ocular cysticercosis (treatment-induced inflammation causes blindness)	STAT	STAT	STAT	STAT
Critical care/ICU team for cysticercal encephalitis with diffuse cerebral edema, elevated ICP, herniation, or respiratory failure	STAT	STAT	-	STAT
Gastroenterology consultation if intestinal taeniasis confirmed for treatment and surveillance	-	ROUTINE	ROUTINE	-
Endocrinology consultation for corticosteroid-induced diabetes management during prolonged steroid courses (especially subarachnoid NCC requiring months of therapy)	-	ROUTINE	ROUTINE	-
Public health notification and household contact screening for Taenia solium (stool examination of household members; identify tapeworm carrier to prevent ongoing transmission)	-	ROUTINE	ROUTINE	-
Pharmacy consultation for drug interaction management (praziquantel interactions with enzyme-inducing AEDs; albendazole bioavailability optimization; cimetidine boosting)	-	ROUTINE	ROUTINE	-
Physical therapy for deconditioning prevention and rehabilitation if focal deficits present	-	ROUTINE	ROUTINE	-
Social work for discharge planning, medication access (albendazole availability), immigration/insurance barriers common in endemic populations	-	ROUTINE	ROUTINE	-
Neuropsychology referral if cognitive complaints persist after treatment (encephalitis, multiple cysts, or chronic hydrocephalus cause lasting cognitive impact)	-	ROUTINE	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Return to ED immediately if worsening headache, new confusion, seizure, fever, new weakness, vision changes, or vomiting (indicates treatment-induced inflammation, hydrocephalus, or cysticercal encephalitis)	STAT	STAT	ROUTINE
Take albendazole WITH a fatty meal (increases drug absorption 5-fold; without fat, most of the drug is not absorbed and treatment fails)	-	ROUTINE	ROUTINE
Do NOT stop corticosteroids abruptly (adrenal crisis risk with sudden discontinuation; taper as directed by physician; risk increases after >2 weeks of use)	-	ROUTINE	ROUTINE
Report any yellowing of skin/eyes, dark urine, or right upper abdominal pain (signs of albendazole hepatotoxicity requiring medication hold and evaluation)	-	ROUTINE	ROUTINE
Take antiseizure medications as prescribed; do NOT stop abruptly (risk of breakthrough seizure; NCC is the leading cause of adult-onset epilepsy worldwide)	-	ROUTINE	ROUTINE
Do NOT drive until cleared by neurology due to seizure risk (state laws typically require 3-12 months seizure-free; NCC-related seizures recur even after cyst resolution)	-	ROUTINE	ROUTINE
Follow-up MRI scans are essential to confirm cyst resolution (typically at 3 and 6 months after treatment; some cysts take 12+ months to fully resolve or calcify)	-	ROUTINE	ROUTINE
Report any vision changes immediately (indicates ocular cysticercosis or treatment-related intraocular inflammation)	-	ROUTINE	ROUTINE
Ensure household members are screened for intestinal Taenia solium by stool examination (identifying and treating the tapeworm carrier prevents ongoing transmission)	-	ROUTINE	ROUTINE
Practice strict hand hygiene and food safety: wash hands thoroughly before eating and after using the restroom; wash all fruits and vegetables; cook pork to internal temperature of >=145F (63C)	-	ROUTINE	ROUTINE
Bring all medications to every follow-up visit for medication reconciliation and compliance assessment	-	ROUTINE	ROUTINE
Follow-up with neurology in 4-6 weeks for seizure assessment, AED level monitoring, and imaging review	-	ROUTINE	ROUTINE
Follow-up with infectious disease in 2-4 weeks for antiparasitic treatment response assessment and lab monitoring	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Food safety education: thoroughly cook all pork products to internal temperature >=145F (63C); avoid raw or undercooked pork (prevents intestinal tapeworm acquisition)	-	ROUTINE	ROUTINE
Hand hygiene education: wash hands with soap and water before preparing food, before eating, and after using the restroom (fecal-oral transmission of T. solium eggs causes cysticercosis)	-	ROUTINE	ROUTINE
Water safety: drink boiled or filtered water in endemic areas; avoid consuming water potentially contaminated with human feces	-	ROUTINE	ROUTINE
Seizure safety precautions: avoid heights, swimming alone, unsupervised bathing, and operating heavy machinery until seizure-free period established per neurology guidance	-	ROUTINE	ROUTINE
Glycemic control optimization during corticosteroid therapy (monitor glucose closely; initiate insulin or oral hypoglycemic agents during treatment as needed)	-	ROUTINE	ROUTINE
Bone health: calcium 1000-1200 mg/day and vitamin D 1000-2000 IU/day supplementation during prolonged corticosteroid use (>3 months); DEXA scan if prolonged steroid course anticipated	-	ROUTINE	ROUTINE
Screen household contacts for T. solium tapeworm carriage with stool O&P and/or coproantigen testing (public health imperative to interrupt transmission cycle)	-	ROUTINE	ROUTINE
Travel counseling for patients returning to endemic areas: emphasize food and water hygiene, pork cooking practices, and sanitation	-	-	ROUTINE
Avoid alcohol during antiparasitic therapy (hepatotoxicity risk with albendazole potentiated by alcohol; impairs medication compliance)	-	ROUTINE	ROUTINE
Stress management and mental health support (chronic disease management; immigration-related stressors common in endemic populations; seizure-related anxiety and depression)	-	ROUTINE	ROUTINE
Gradual return to work and daily activities with seizure precautions; driving restrictions per state law; employer notification if safety-sensitive occupation	-	-	ROUTINE
Women of childbearing age: effective contraception MANDATORY during albendazole therapy and for 1 month after completion (albendazole is teratogenic)	-	ROUTINE	ROUTINE
Follow-up imaging schedule: MRI at 3 months, 6 months, 12 months, then annually until cyst resolution confirmed and seizure-free; longer follow-up for subarachnoid NCC	-	ROUTINE	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Tuberculoma	Endemic area overlap; ring-enhancing or solid nodular lesion; conglomerate lesions; basilar meningeal enhancement; no scolex; slower progression; constitutional symptoms	QuantiFERON-TB Gold; chest imaging; AFB culture; CSF TB PCR; biopsy with caseating granulomas; response to anti-TB therapy; NO scolex on imaging
Brain abscess	Ring-enhancing lesion with DWI restriction; fever; acute presentation; peripheral leukocytosis; thinner wall on ventricular side; no scolex	MRI DWI (restricted diffusion = abscess; NCC does NOT restrict); blood cultures; fever pattern; surgical aspiration with Gram stain and culture
Brain metastasis	Multiple ring-enhancing lesions at gray-white junction; known primary malignancy; progressive neurologic decline; no scolex; surrounded by vasogenic edema	CT chest/abdomen/pelvis for primary; no DWI restriction; no scolex; no calcifications; biopsy if uncertain
High-grade glioma (GBM)	Irregular thick ring enhancement; necrotic center without scolex; older age; progressive over weeks; mass effect disproportionate to size	MRI DWI (no restriction); MR spectroscopy (elevated choline); PET (hypermetabolic); biopsy
Toxoplasmosis	HIV/AIDS with CD4 <100; multiple ring-enhancing lesions in basal ganglia; no scolex; responds to empiric therapy within 2 weeks	Toxoplasma IgG (>95% positive); CD4 count; empiric treatment trial; no calcifications; serology
Primary CNS lymphoma	Periventricular homogeneous enhancement; immunocompromised or immunocompetent; no scolex; responds dramatically to steroids (ghost tumor)	MRI (homogeneous enhancement); CSF cytology; EBV PCR in CSF; avoid steroids before biopsy; no calcifications
Meningioma	Extra-axial dural-based mass; homogeneous enhancement with dural tail; no scolex; no calcification pattern of NCC	MRI (extra-axial, dural-based, dural tail); no DWI restriction; no ring enhancement; biopsy if uncertain
Colloid cyst (third ventricle)	Anterior third ventricle location; hyperdense on CT; no enhancement; intermittent hydrocephalus; positional headache	CT (hyperdense third ventricle cyst); MRI (variable signal but no scolex); no enhancement; no serologic markers
Arachnoid cyst	CSF-intensity cyst WITHOUT scolex; no enhancement; no perilesional edema; no calcification; congenital; asymptomatic or mass effect	MRI (CSF signal on ALL sequences, no scolex, no enhancement, no FLAIR signal); negative serology; stable on serial imaging
Epidermoid cyst	CSF-like cyst on T1/T2 but RESTRICTS on DWI (unlike arachnoid cyst); pearly white appearance; extra-axial; no scolex	MRI DWI (restricted diffusion unlike NCC cyst); no enhancement; no scolex; no calcification; no serology
Cavernous malformation	Popcorn-like lesion with hemosiderin rim; mixed signal on MRI; no enhancement (typically); seizures; no scolex; blooming on GRE/SWI	MRI GRE/SWI (prominent hemosiderin blooming); no enhancement; no scolex; gradient echo sequences diagnostic; negative serology
Calcified AVM or old hemorrhage	Calcification on CT; mimics calcified NCC; vascular flow voids on MRI; history of hemorrhage or incidental finding	CTA/MRA (vascular malformation); angiography (definitive); no scolex; negative serology; different calcification pattern

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Neurologic exam (GCS, pupils, motor, speech)	STAT	STAT	ROUTINE	STAT	q2-4h inpatient; each OPD visit	Stable or improving; no new focal deficits	If declining: STAT CT; assess for treatment-induced inflammation, hydrocephalus; hold antiparasitic if worsening; increase corticosteroids
Temperature	STAT	STAT	ROUTINE	STAT	q4h (q1h if febrile)	Afebrile; low-grade fever common during cyst degeneration	If persistent high fever: evaluate for bacterial superinfection; cysticercal encephalitis; other etiology
LFTs (ALT, AST, bilirubin)	-	ROUTINE	ROUTINE	ROUTINE	Baseline; day 7; day 14 of albendazole; then biweekly during treatment	ALT/AST <3x ULN	If ALT/AST >3x ULN: HOLD albendazole; recheck in 1 week; resume at lower dose if normalized or switch to praziquantel monotherapy
CBC with differential	STAT	ROUTINE	ROUTINE	STAT	Baseline; weekly during antiparasitic therapy; q2 weeks during prolonged courses	WBC >3000; ANC >1500; platelets >100K	If leukopenia or thrombocytopenia: hold albendazole; recheck in 1 week; dose reduction
Blood glucose	STAT	ROUTINE	ROUTINE	STAT	q6h during IV dexamethasone; daily during oral steroid taper; each OPD visit	Glucose <180 mg/dL; HbA1c <7%	If persistently elevated: start insulin sliding scale or oral hypoglycemic; endocrine consultation for prolonged steroid courses
Serum sodium	STAT	ROUTINE	-	STAT	Daily x 3 then twice weekly inpatient; each OPD visit during steroid taper	135-145 mEq/L	If <130: SIADH workup; fluid restriction; if <120: 3% saline
Antiepileptic drug levels	-	ROUTINE	ROUTINE	ROUTINE	Once at steady state; after dose changes; if breakthrough seizures	Therapeutic range for specific AED	Adjust dosing; assess compliance; drug interaction review
Serial MRI brain with contrast	-	ROUTINE	ROUTINE	ROUTINE	At 3 months, 6 months, 12 months post-treatment; then annually until resolved	Cyst resolution (disappearance or calcification); no new cysts; decreasing edema; no new enhancement	If enlarging or new cysts: retreat with antiparasitic; if new edema around calcification: short steroid course; neurosurgery if hydrocephalus
Seizure monitoring (clinical + EEG)	STAT	STAT	ROUTINE	STAT	Clinical: continuous inpatient; EEG if altered consciousness; OPD: seizure diary	No seizure activity	If seizures: optimize AED levels; add second agent; continuous EEG in ICU; assess for new cyst inflammation
CSF antigen levels (subarachnoid NCC)	-	ROUTINE	ROUTINE	-	Baseline; at 3 months; at 6 months; then q6 months until negative	Declining cysticercus antigen titer	If rising or stable: treatment failure; extend antiparasitic course; reassess surgical options
ICP (if EVD in place)	-	-	-	STAT	Continuous	ICP <22 mmHg; CPP 60-70 mmHg	Tiered ICP management: CSF drainage, osmotherapy, sedation, surgical decompression
Ophthalmologic exam	-	ROUTINE	ROUTINE	-	Baseline before treatment; at 3 months; if new visual symptoms	No intraocular cysts; stable vision	If new intraocular findings: HOLD antiparasitic; urgent ophthalmology

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home (with outpatient follow-up)	Clinically stable; seizure-free >=48h on AEDs; tolerating oral medications (antiparasitic + steroids + AED); no signs of elevated ICP; no hydrocephalus on imaging; outpatient MRI and lab follow-up arranged; neurology and ID follow-up confirmed within 2-4 weeks; reliable medication access and compliance anticipated
Admit to floor (monitored)	New NCC diagnosis with active parenchymal cysts requiring initiation of antiparasitic therapy under observation; mild headache without signs of elevated ICP; GCS >=14; seizures controlled on medication; monitoring for treatment-induced inflammation during first 48-72h of antiparasitic + steroid initiation
Admit to ICU / Neuro-ICU	Cysticercal encephalitis (massive edema, diffuse viable cysts); acute hydrocephalus requiring EVD; GCS <13 or declining; herniation syndrome; refractory seizures or status epilepticus; post-operative monitoring after craniotomy or endoscopic cyst removal; need for ICP monitoring
Transfer to higher level	Need for neurosurgery not available at current facility (endoscopic cyst removal, VP shunt, craniotomy); need for neuro-ICU expertise; need for continuous EEG not available; need for specialized NCC serologic testing
Outpatient management	Calcified NCC (inactive) with controlled seizures; known NCC on established AED regimen with seizure diary; follow-up imaging and serology monitoring; stable subarachnoid NCC on maintenance steroid/antiparasitic taper

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Del Brutto diagnostic criteria for NCC	Class I, Level A	Del Brutto et al. J Neurol Sci 2017 — revised diagnostic criteria with absolute, major, minor, and epidemiologic criteria
Albendazole 15 mg/kg/day for parenchymal NCC	Class I, Level A	Garcia et al. N Engl J Med 2004 — randomized controlled trial demonstrating albendazole reduces seizure burden and promotes cyst resolution
Combination albendazole + praziquantel for >2 viable cysts	Class I, Level A	Garcia et al. Lancet Infect Dis 2014 — RCT showing combination therapy superior to albendazole alone for multiple cysts
Corticosteroids before and during antiparasitic therapy	Class I, Level A	Garcia et al. N Engl J Med 2004; IDSA/ASTMH Guidelines — White et al. Clin Infect Dis 2018
IDSA/ASTMH Clinical Practice Guidelines for NCC	Class I, Level A	White et al. Clin Infect Dis 2018 — comprehensive guidelines for diagnosis and treatment of NCC
No antiparasitic therapy for calcified NCC	Class I, Level B	White et al. Clin Infect Dis 2018 — calcified lesions are dead parasites; antiparasitic therapy has no target; AEDs for seizures
EITB (immunoblot) as preferred serologic test	Class I, Level A	Tsang et al. J Infect Dis 1989 — EITB sensitivity 94-98% for >1 viable cyst; specificity ~100%
Enzyme-inducing AEDs reduce praziquantel levels by 50-75%	Class I, Level B	Bittencourt et al. Neurology 1992 — phenytoin and carbamazepine significantly reduce praziquantel bioavailability; prefer non-enzyme-inducing AEDs
Ophthalmologic exam mandatory before antiparasitic therapy	Class I, Level C	White et al. Clin Infect Dis 2018 — treatment-induced inflammation causes vision loss in ocular NCC; absolute contraindication
Neuroendoscopy preferred for intraventricular cyst removal	Class IIa, Level B	Sinha & Sharma. Neurosurg Focus 2012 — endoscopic approach offers direct visualization with lower morbidity than open surgery for ventricular cysts
VP shunt for chronic hydrocephalus in subarachnoid NCC	Class IIa, Level B	White et al. Clin Infect Dis 2018 — chronic arachnoiditis causes communicating hydrocephalus requiring permanent CSF diversion
Prolonged antiparasitic therapy for subarachnoid NCC	Class IIa, Level C	Proano et al. Ann Intern Med 2001 — subarachnoid (racemose) NCC requires prolonged courses (months); monitor with CSF antigen
NCC is the leading cause of adult-onset epilepsy worldwide	Class I, Level A	Ndimubanzi et al. PLoS Negl Trop Dis 2010 — systematic review confirming NCC accounts for ~30% of epilepsy in endemic areas
Methotrexate as steroid-sparing agent for subarachnoid NCC	Class IIb, Level C	Mitre et al. Clin Infect Dis 2007 — case series supporting methotrexate for chronic arachnoiditis requiring prolonged immunosuppression
Albendazole bioavailability increased 5-fold with fatty meal	Class I, Level B	Mottier et al. J Pharm Pharmacol 2006 — pharmacokinetic studies demonstrating critical importance of fatty meal for drug absorption
Cysticercal encephalitis: no antiparasitic initially	Class I, Level C	White et al. Clin Infect Dis 2018 — antiparasitic drugs worsen cerebral edema in cysticercal encephalitis; control edema first with corticosteroids and ICP management
Dexamethasone increases albendazole sulfoxide levels by 50%	Class I, Level B	Jung et al. J Clin Pharmacol 1990 — pharmacokinetic synergy; concurrent dexamethasone enhances albendazole efficacy
Serial MRI for monitoring treatment response	Class I, Level B	Expert consensus; White et al. Clin Infect Dis 2018 — imaging at 3 and 6 months; cyst resolution or calcification confirms successful treatment

CHANGE LOG¶

v1.1 (February 2, 2026) - Checker/rebuilder pipeline revision (all findings approved) - C1: Replaced hedging language in staging table granular nodular row ("may be considered" -> "Antiparasitic therapy for residual viable elements") - C2: Clarified albendazole dosing (standard max 800 mg/day; up to 1200 mg/day for heavy disease per ID specialist) - C3: Added ICU column to LP table for all 10 CSF studies with appropriate priorities - C4: Removed incorrect CPT 96374 from albendazole (oral medication, not IV push) - S1: LP table ICU column populated (URGENT for acute studies, ROUTINE for specialized) - S2: Added HOSP = URGENT for mannitol and hypertonic saline (usable on monitored floors) - M1: Converted staging table hedging to directives; ventricular row updated to directive phrasing - M2: Clarified levetiracetam titration (titrate by 500 mg/day every 2 weeks to 1500 mg BID) - M3: Pneumatic compression device dosing field corrected (N/A for dose) - R1: Removed hedging language throughout ("may suggest" -> "indicates", "may cross-react" -> "cross-reacts", "can be fatal" -> "is fatal", "can destroy" -> "destroys", "can cause" -> "causes", "may indicate" -> "indicates", "may fail" -> "fails", "may recur" -> "recur", "may require" -> "requires/as needed", "consider" -> "evaluate for") - R2: 4B/4C tables corrected to 4-column format (ED, HOSP, OPD — no ICU per spec) - R3: VP shunt contraindication updated from "may need" to "requires" - R4: ETV indication updated from "may be combined" to "combine when feasible" - R5: Lorazepam dosing updated from "may repeat" to "repeat x1 if seizure continues" - R6: Prednisone taper updated from "may require years" to "years for chronic arachnoiditis" - R7: Methotrexate onset updated from "may take 4-6 weeks" to "onset of effect 4-6 weeks" - R8: Appendix B granular nodular treatment updated to match staging table directive - Updated version to 1.1; added REVISED date

v1.0 (February 2, 2026) - Initial template creation - Comprehensive 8-section format covering neurocysticercosis diagnosis, staging, antiparasitic therapy, seizure management, and follow-up - All four anatomic forms covered: parenchymal, ventricular, subarachnoid (racemose), and spinal NCC - Staging-based treatment approach: vesicular, colloidal vesicular, granular nodular, calcified - Antiparasitic regimen: albendazole monotherapy for 1-2 cysts; combination albendazole + praziquantel for >2 cysts - Drug interaction management: enzyme-inducing AEDs reduce praziquantel levels; cimetidine as booster - Del Brutto diagnostic criteria referenced - Surgical management: neuroendoscopy for ventricular cysts, VP shunt for chronic hydrocephalus, craniotomy indications - Mandatory ophthalmologic exam before antiparasitic therapy - Cysticercal encephalitis management (no antiparasitic initially) - Steroid-sparing agents (methotrexate) for chronic subarachnoid NCC - Public health measures: household contact screening, intestinal tapeworm treatment - IDSA/ASTMH 2018 guidelines as primary evidence source

APPENDIX A: DEL BRUTTO DIAGNOSTIC CRITERIA (2017 REVISED)¶

Absolute Criteria (any one = definitive diagnosis)¶

Criterion	Details
Histologic demonstration	Parasitic structures (scolex, cyst wall) in CNS tissue from biopsy or autopsy
Cystic lesion with scolex on CT or MRI	Pathognomonic: visualization of scolex (bright dot) within a cystic lesion on neuroimaging
Fundoscopic visualization	Direct visualization of subretinal cysticercus by ophthalmoscopy

Neuroimaging Criteria¶

Category	Findings
Major	Cystic lesions without scolex; enhancing lesions; multilobulated cysts in subarachnoid space (racemose); typical parenchymal calcifications
Confirmatory	Resolution of cystic lesions after antiparasitic therapy; spontaneous resolution of single enhancing lesion (compatible with natural history); migration of ventricular cyst on sequential imaging
Minor	Obstructive hydrocephalus; abnormal enhancement of basal leptomeninges; myelographic filling defect in spinal canal

Clinical/Exposure Criteria¶

Category	Findings
Major	Positive serum cysticercosis EITB (immunoblot); resolution of intracranial cystic lesion after albendazole/praziquantel therapy; cysticercosis outside CNS (subcutaneous/intramuscular cigar-shaped calcifications)
Minor	Clinical manifestations suggestive of NCC (seizures, focal deficits, elevated ICP); positive CSF ELISA for cysticercal antigen or antibody; individual from or living in endemic area

Diagnostic Categories¶

Diagnosis	Criteria Required
Definitive NCC	1 absolute criterion; OR 2 major neuroimaging + 1 clinical/exposure criteria
Probable NCC	1 major neuroimaging + 2 clinical/exposure criteria; OR 1 major + 1 confirmatory neuroimaging + 1 clinical/exposure criteria; OR 1 major neuroimaging + 1 clinical/exposure + 1 epidemiologic criterion

APPENDIX B: NCC STAGING AND IMAGING CHARACTERISTICS¶

Stage	Timeline	CT Findings	MRI Findings	Pathology	Treatment Implication
Vesicular (viable)	Months to years after infection	Well-defined cyst (CSF density); scolex visible as eccentric dot; no enhancement; minimal/no edema	Cyst = CSF signal on all sequences; scolex bright on FLAIR/T1+C; no surrounding edema; no restriction on DWI	Viable larva with intact membrane; minimal host immune response	Antiparasitic therapy indicated; corticosteroids for inflammation
Colloidal vesicular (degenerating)	Host immune response begins	Ring-enhancing cyst; perilesional edema; cyst contents slightly hyperdense to CSF	Ring enhancement; cyst fluid brighter than CSF on FLAIR and T1; perilesional edema (T2/FLAIR hyperintensity); scolex still visible	Degenerating larva; thick capsule; intense inflammatory infiltrate; colloidal fluid	Antiparasitic therapy + corticosteroids; most symptomatic stage
Granular nodular (involuting)	Cyst shrinking	Enhancing nodule or small ring-enhancing lesion; less edema than colloidal stage; lesion shrinking	Nodular or ring enhancement; decreasing size; less perilesional edema; scolex no longer visible	Larval remnants; dense collagen capsule; granulomatous inflammation	Antiparasitic therapy for residual viable elements; corticosteroids if symptomatic edema
Calcified (inactive/dead)	Years post-infection	Calcified nodule (best seen on CT); small, round, dense calcification; no enhancement unless perilesional edema	T2/GRE/SWI hypointense (dark); perilesional edema possible (seizure trigger); NO enhancement of calcification itself	Dead parasite; calcium deposits; gliotic scar; mineralized remnant	NO antiparasitic (cyst is dead); AEDs for seizures; short steroid course for perilesional edema

APPENDIX C: DRUG INTERACTION MANAGEMENT FOR NCC¶

Drug Interaction	Clinical Effect	Management
Phenytoin/carbamazepine + praziquantel	Enzyme-inducing AEDs reduce praziquantel levels by 50-75% (CYP3A4 induction)	Switch to non-enzyme-inducing AED (levetiracetam, lacosamide) if possible; if not possible: increase praziquantel dose to 100 mg/kg/day OR add cimetidine 400 mg TID
Dexamethasone + praziquantel	Dexamethasone reduces praziquantel levels by ~50% (CYP3A4 induction)	Add cimetidine 400 mg TID; monitor clinical response; increase praziquantel dose if needed
Dexamethasone + albendazole	Dexamethasone INCREASES albendazole sulfoxide (active metabolite) levels by ~50%	Beneficial interaction; no dose adjustment needed; enhances albendazole efficacy
Cimetidine + praziquantel	Cimetidine inhibits CYP3A4, increases praziquantel bioavailability 2-fold	Use cimetidine 400 mg TID when enzyme-inducing AEDs or dexamethasone reduce praziquantel levels
Albendazole + fatty meal	Fat increases albendazole absorption 5-fold	ALWAYS take albendazole with fatty meal; counsel patient on importance
Valproate + albendazole	No significant interaction	Safe combination; no dose adjustment
Levetiracetam + albendazole/praziquantel	No significant interaction	Preferred AED for NCC due to no enzyme induction
Lacosamide + albendazole/praziquantel	No significant interaction	Safe alternative AED; no enzyme induction
Phenobarbital + praziquantel	Reduces praziquantel levels (CYP3A4 induction)	Avoid; switch to non-enzyme-inducing AED

APPENDIX D: TREATMENT DURATION BY NCC TYPE¶

NCC Type	Antiparasitic Duration	Steroid Duration	AED Duration	Follow-up Imaging
1-2 parenchymal cysts (viable)	Albendazole 7-14 days	Dexamethasone: start 1 day before, taper over 2-4 weeks	Continue >=2 years seizure-free; trial withdrawal if cyst resolved and EEG normal	MRI at 3 and 6 months; annual until resolved
>2 parenchymal cysts (viable)	Albendazole + praziquantel 10-14 days	Dexamethasone: start 1 day before, taper over 2-4 weeks	Continue >=2 years seizure-free	MRI at 3 and 6 months; annual until resolved
Calcified (inactive)	NONE (cyst is dead)	Short course (5-7 days) only if perilesional edema	Lifelong if recurrent seizures; trial AED withdrawal after >=2 years seizure-free	CT at 6-12 months to confirm stable calcification
Ventricular	Antiparasitic after surgical cyst removal if viable cysts remain	Variable based on inflammation	Per seizure management	MRI at 1, 3, 6, 12 months; assess shunt function
Subarachnoid (racemose)	Prolonged: weeks to months (repeat courses common); monitor with CSF antigen until negative	Prolonged: months to years; steroid-sparing agents (methotrexate) for chronic arachnoiditis	Per seizure management; often prolonged	MRI + CSF antigen q3-6 months until antigen negative
Spinal	Antiparasitic after surgical excision if accessible; medical therapy if diffuse or inoperable	Prolonged during treatment	If seizures present	MRI spine at 3, 6, 12 months
Cysticercal encephalitis	DELAYED: only after edema controlled (weeks); start low dose	HIGH-DOSE: dexamethasone 0.15-0.3 mg/kg q6h; prolonged taper	Aggressive AED management; often requires multiple agents	MRI at 2 weeks, then monthly until stable