CME Albendazole trial at 15 or 30 mg/kg/day for subarachnoid and intraventricular cysticercosis Abstract—Thirty-six patients with subarachnoid and intraventricular cystic- ercosis were randomly assigned to receive albendazole at 15 or 30 mg/kg/day plus dexamethasone for 8 days. Results favored a higher dose, with larger cyst reduction on MRI at 90 and 180 days and higher albendazole sulfoxide levels in plasma. An albendazole course at 30 mg/kg/day combined with corticosteroids is safe and more effective than the usual dose. A single treatment was insuffi- cient in intraventricular and giant cysts. NEUROLOGY 2006;66:436–438 F. Go ´ngora-Rivera, MD; J.L. Soto-Herna ´ ndez, MD; D. Gonza ´ lez Esquivel, MS; H.J. Cook, PhD; C. Ma ´ rquez-Caraveo, MD; R. Herna ´ndez Da ´ vila, MD; and J. Santos-Zambrano, MD Treatment of subarachnoid and intraventricular neurocysticercosis (NCC) is controversial. 1-3 An open trial of albendazole treatment required repeated courses and years of follow-up to observe complete response. 4 Long-term follow-up is difficult in develop- ing countries in which NCC is most prevalent. A pilot study of 12 patients with subarachnoid cysticer- cosis explored the efficacy of albendazole at a dose of 30 mg/kg/day for 15 days. At 6 months, follow-up MRI revealed 80% reduction of the initial cyst vol- ume. 5 Based on a controlled trial of short vs long courses of albendazole in the treatment of parenchy- mal NCC without significant differences in long-term results, 6 we chose 8 days as the treatment duration for a randomized trial of two doses of albendazole in patients with subarachnoid or intraventricular cys- ticercosis. Albendazole sulfoxide concentrations were determined in plasma and CSF. 7 Methods. This randomized trial was conducted at a reference center. Adult patients were included and hospitalized during base- line evaluation and albendazole treatment. The follow-up period was 180 days. Diagnosis of subarachnoid and intraventricular cysticercosis for purposes of the study required lesions on initial CT scan that were highly suggestive of NCC, clinical manifesta- tions of NCC, and residence in cysticercosis endemic areas. An ELISA test in CSF for cysticercal antibodies was obtained at base- line. All patients were pretreated with 8 mg IV dexamethasone every 8 hours during 4 days, and on the fifth day, patients re- ceived either 15 mg/kg/day (Group A) or 30 mg/kg/day (Group B) albendazole. The primary efficacy measure was the reduction in percentage of cyst volume from baseline CT with CT performed at 7 and 30 days, and baseline MRI compared with MRI at 90 and 180 days. For detailed methods and statistical analysis, see the supplemental materials on the Neurology Web site at www.neurology.org. Results. Thirty-six patients were randomized, and five did not complete the study. Two patients in Group A did not complete the trial. One patient died of acute pulmo- nary embolism on the first day of dexamethasone pretreat- ment; no autopsy was granted. The second patient was lost to follow-up at the third month. Three patients in Group B did not complete the trial. Two patients randomized by CT scan discontinued early because of an alternative diagno- sis. In one patient, MRI revealed inflammatory entrap- ment of the fourth ventricle by chronic arachnoiditis. Another patient with a presumed fourth ventricle cysticer- cus had MRI findings compatible with an intraventricular neoplasm; surgery revealed an ependymoma. The third pa- tient was lost to follow-up at 3 months, and the 30-day CT scan was evaluated. Figure 1 illustrates the trial profile. Baseline characteristics of the two treatment groups were similar. The signs and symptoms score (SSS) was higher in Group B (table). NCC localization was similar in both groups: subarachnoidal cysts alone were present in 11 pa- tients in each group; intraventricular cysts, localized within the lateral or fourth ventricle, were present in three and five patients in Groups A and B, respectively. Mixed forms, with subarachnoidal and intraventricular or paren- chymal cysts, were present in two and four patients in Groups A and B, respectively. In mixed forms, parenchy- mal cysts were not considered for the efficacy analysis. One day after dexamethasone pretreatment, a marked improvement in clinical manifestations was observed in most patients. The mean SSS was reduced at 7 days, from 4 points to 1 point in Group A and from 6 points to 1 point in Group B. Thereafter, no significant increase in symp- toms occurred in either group. Six patients required a ven- triculoperitoneal shunt placement before albendazole treatment. Anticysticercal antibody test results by ELISA were positive on the initial CSF sample in 13 of 16 patients in Group A and 17 of 20 patients in Group B. In follow-up CSF studies, only the patient excluded by fourth ventricle ependymoma had a negative ELISA result. At 6 months, CSF protein concentrations remained increased, at 172  391 mg/dL in Group A and 47  44 mg/dL in Group B. No differences in CSF cell counts/mm 3 , 51  14 in Group A and 22  37 in Group B, were observed at 6 months. Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Con- tents for the February 14 issue to find the title link for this article. This article was previously published in electronic format as an Expedited E-Pub on December 28, 2005, at www.neurology.org. From the Department of Neurology (F.R-G., C.M.-C., R.H.D., J.S.-Z.), De- partment of Infectious Diseases (J.L.S.-H.), and Neuropharmacology Labo- ratory (D.G.E., H.J.C.), Instituto Nacional de Neurologı ´a y Neurocirugı ´a Manuel Velasco Sua ´ rez, Mexico City, Mexico. Disclosure: The authors report no conflicts of interest. Received May 16, 2005. Accepted in final form October 27, 2005. Address correspondence and reprint requests to Dr. Jose ´ Luis Soto-Herna ´ ndez, Department of Infectious Disease, Instituto Nacional de Neurologı ´a y Neuro- cirugı ´a Manuel Velasco Sua ´ rez, Insurgentes Sur 3877, Tlalpan 14269, D.F., Mexico City, Mexico; e-mail: joseluis_sotohernandez@yahoo.com 436 Copyright © 2006 by AAN Enterprises, Inc.