Evidence-based guideline: Treatment of parenchymal neurocysticercosis: report of the Guideline Development Subcommittee of the American Academy of Neurology.

Comments on an article by Ruth Ann Baird et al. (see record [rid]2013-13289-012[/rid]). The success of a systematic review lies in the adequate selection of the questions that represent the daily problems encountered by treating physicians. NCC is a pleomorphic disease and the clinical behavior of patients harboring one cystic lesion is different from those with multiple intraparenchymal lesions. Confounders can also play an important role in the treatment of NCC including the patient’s concomitant use of other medications and stage of the lesions. These factors were not considered in the review by Baird et al. The authors should have performed systematic reviews in each of the following groups independently: single lesion, multiple lesions, and cysticercotic encephalitis. Baird et al. demonstrated that there are few evidence-based studies of antihelminthic treatment for NCC. This guideline has some limitations. The authors’ procedure was to evaluate treatment based on the reduction of number of cysts. This method is misleading because if only one cyst out of many remains alive after treatment, it could prompt continued or recurrence of symptoms. In the guideline by Baird et al., nine of the studies used in the meta-analysis included patients with single parenchymal cysts, while 4 studies included patients with between 36 and up to 100 cysts. These comparisons are not appropriate, because single cysts are considered benign, whereas multiple cysts can be lethal. In addition, seizure control was used as the only clinical outcome measurement, despite other common manifestations such as encephalopathy, headache, paresis, and dementia. The current practice, especially in patients who harbor a high parenchymal NCC load, is to pretreat the patient with steroids (dexamethasone or prednisone) for 5–7 days before commencing cysticidal therapy with albendazole. A future AAN evidence-based guideline should also address management issues concerning solitary parenchymal NCC granuloma, which may disappear on its own, an entity commonly reported in the Indian subcontinent.