Abstract: --

Neurocysticercosis is one of the most common cerebral parasitosis with diverse neuropsychiatric manifestation .Out of Eighty four confirmed cases of neuro-cysticercosis (N.C.C.) with the help of M.R.I. & ELISA test, only forty two cases were taken for the study of therapeutic efficacy of Albendazole (ABZ) in various types of neuro-cysticercosis. Twenty-seven cases had solitary benign parenchymal lesions, eleven cases had multiple scattered parenchymal lesions where as four patients had extra parenchymal & complicated parenchymal lesions with hydrocephalous & cerebral abscess etc. Their most common clinical presentations were seizure, headache & mental deterioration.

Comparative therapeutic responses of ABZ between single parenchymal Vs multiple parenchymal & extra parenchymal with complicated NCC revealed that the efficacy & cure rate was more better i.e. 96% in single parenchymal N.C.C. than 82 % in multiple parenchymal N.C.C. & 75 % in extra parenchymal N.C.C. So the ABZ therapy was more better & effective in single benign parenchymal N.C.C. than latter two types of multiple parenchymal & extra parenchymal complicated N.C.C. This type of cerebral cysticercosis responses well to ABZ with oral steroid & anticonvulsant.

INTRODUCTION: -

Surgeon H. Armstrong first reported Neurocysticercosis in Madras asylum (India) in 1888 from post mortem in neuropsychiatric patients. Since then there have been many case reports from various parts of the world. It is the larval or intermediate state of infection with the Taenia Solium. Ingesting contaminated raw vegetables, salads, undercooked infected meat of the pork & cattle infects humans, drinking contaminated water. External autoinfection occurs from transmission of eggs from anus to mouth by inadequate personal hygiene. Internal autoinfection results after regurgitation of the ova from small intestine into stomach. Cysticerci emerge from the intestinal wall through mesenteric vessel encysts the brain parenchyma, ventricle, meninges, encephalon, subarachnoid space & eyes. The cysts may be (1) with centrally placed "Mural Nodule" representing the scolex in live cyst (2) edematous " Mural Nodule" with viable parasite (3) granulomatous cysticercous lesions (4) dead parasite with fibrotic capsulated cyst & (5) cyst with calcified ring. The cyst may be (1) Single Parenchymal (2) Multiple Parenchymal cysts scattered throughout the brain parenchymal (3) or Multiple Cerebral Parenchymal cysts with secondary complication i.e. cortical atrophy due to neuronal damage & cerebral abscess & ventricular dilatation. Meningeal & intraventricular cyst blocks the C.S.F. pathways producing obstructive hydrocephalous manifesting head ache, dementia & seizure. Cysticerci invasion of the brain induces inflammatory reaction to meninges, encephalon & vascular regions, resulting meningo-encephalitis & vasculitis.

Symptoms of nervous system involvement depend upon the (1) site of the cyst (2) & number of the larva or (3) State of the lesion activity & (4) host immune response.

Neurocysticercosis is a space occupying lesions of the brain shows the symptoms of brain tumor, cerebral dysfunction like epilepsy, dementia, somatic & behavioral disturbances like head ache, dizziness, nausea & vomiting, violent behavior, mental disturbances as anxiety, manic episode & depression. Those symptoms occur in variable combination, mimicking acute or chronic Organic Brain Syndrome. Lack of physical & neurological findings, neurosurgeons & physicians under rate physical causes as a possible basis for the mental symptoms. Few patients were studied for the neuropsychiatric manifestation, site of cerebral lesions & therapeutic responses with different cysticides.

AIMS: -

Present study was undertaken with following aims: -

Samples: - Out of eighty-four confirmed patients of Neurocysticercosis, 42 were taken for the study. The patients were selected on the basis of proven Neurocysticercosis by the presence of distinct image of parasite in M.R.I. brain. The patients not satisfying the DSM III criteria of Organic Brain Syndrome were excluded from the study.

METHODS: -

Initially, the especially self-designed socio-demographic data sheet was administered to all the patients for the detail demographic study. The patients underwent complete physical, neuropsychiatric & mental state examination. A symptoms check list & rating scale was administered for all the patients to study cerebral dysfunction, symptoms related behavior, somatic disorders, reactive & neurological symptoms. Folstein Mini Mental State Examination protocol was used twice before & after treatment for assessing the cognitive functioning. M. R.I Brain was done before & after completion of treatment for the evaluation of drug efficacy & resolution rate of cerebral lesions. The efficacy of different regimens of therapy for various types of Neurocysticercosis with ABZ was compared in forty-two patients. These patients were subjected to ABZ therapy to evaluate therapeutic responses of them. These patients were subdivided into three groups according to various modalities of Neurocysticercosis observed in M.R.I. brain. The division was based on the following criteria: -

RESULT: -

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30Days 60Days

TYPES OF N.C.C.	IMPRV NO %	NPRV NO %	IMPRV NO %	NPRV NO %
1 SINGLE PARENCHYMAL NCC—27	26(96.3)	1(3.7)	1(3.7)	NIL
2 MULTIPLE PARENCHYMAL NCC—11	9(81.81)	2(18.2)	2(18.2)	NIL
3 EXTRA PARENCHYMAL COMPLICATED NCC—4	3(75)	1(25)	1(25)	NIL
TOTAL	38(90)	4(9.52)	4(9.52)	NIL
TOTAL CURE RATE	38(90)		4(9.52)
TOTAL FAILURE RATE		4(9.52)		NIL

Therapeutic responses of ABZ in different types of N.C.C., this analysis showed the efficacy of ABZ was more effective for Single Parenchymal in contrast to Multiple Parenchymal & Extra Parenchymal i.e.26 (96.29%) Vs 9(81.81%), 26(96.29%) Vs 3(75%). ABZ was more effective in all the cases of N.C.C. because of increased plasma C.S.F. levels of ABZ as report of the Jung & et al 1990. Dexamethasone increases plasma levels of ABZ resulting increased efficacy of ABZ agrees with the findings of Medina et al 1990.

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PR.TMT POST TMT POST TMT

30DAYS 60DAYS

TYPES OF N.C.C	NO %	DISAP NO %	N.DISAP NO%	DISAP NO %	N.DISAP NO %
1.SINGLE PARENCHYMAL NCC—27	64	26(96)	1(4)	1(4)	NIL
2.MULTIPLE PARENCHYMAL N.C.C.11	26	9(82)	2(18)	2(18)	NIL
3.EXTRA PARENCHYMAL & COMPLICATED N.C.C--4	9.52	3(75)	1(25)	1(25)	NIL
TOTAL RESOLUTION RATE		38(90.47)		4(9.52)	NIL

The study of M.R.I. brain findings after ABZ treatment showed that out of 27(64%) Single Parenchymal N.C.C., 26(96%) resolved within 30 days 1(4%) resolved after 60 days treatment. Out of 11(26%) Multiple Parenchymal N.C.C., 9(82%) lesions resolved by 30 days, 2(18%) lesions resolved by 60 days. Out of 4(9.52%) Extra Parenchymal N.C.C. & complicated N.C.C., 3(75%) lesions resolved by 60days treatment. Comparative study of resolution rate with ABZ in between Single, Multiple, Extra Parenchymal & complicated N.C.C., the former was better than last two types of cerebral lesion i.e. Single Parenchymal N.C.C. 26(96%0 Vs Multiple 9(82%) Vs Extra Parenchymal 3(75%).

Study of side effects reported with ABZ had minimum side effects. It showed CNS undesired effects i.e. one patient had encephalitis, another one altered sensorium, 2 hyperpyrexia, 2 status epilepticus, 4 cases had G.I.T. disorder & all were improved by one week

C.S.F. analysis revealed that 34 (40%) patients had increased intracranial pressure, 58 (69%) had pleocytosis, 77 (91.66%) had more than 30 mg % protein, 52 (61.90%) patients had more than 50 mg % sugar, 84 patients had total WBC count more than 5000 cu mm, 39 patients had eosinophil more than 10 cells.

DISCUSSION: -

Cursed area with inadequate sanitation & fecal contamination leads to the spread of the eggs to the ignorant consumer i.e. pigs, cattle, humanbeings, chicken & fishes etc. Ingestion of unhygienic undercooked, infected tissues, infection by ano oral route or regurgitation of matured segments of cysts from small intestine into the stomach leads to cysticercosis involving subcutaneous tissues, brain, eyes, skeletal muscles, heart, lung & abdominal cavity. It represents a great health hazard in Nepal.

This study revealed that it usually affects the young man less than 34 years old, because of their migratory habit but the children below 10 years of age also had N.C.C. incontrast to previous report which indicates severe health problem in undeveloping country like Nepal. So urgent need is felt to understand its pathophysiology, therapeutic implication of N.C.C. Mostly male patients 59(70.23%) were affected by N.C.C. incontrast to female patients 25(29.76%) because of their frequent transfer from one unit to another, they are mostly vulnerable to N.C.C. from the endemic area & also having migratory habit for better job. Low socio economical status groups 59(70.23%) were more susceptible to N.C.C. in contrast to middle & upper class patients because of poor personal hygiene. Non vegetarian group 75(89.28%) had higher frequency of N.C.C. in contrast to Brahmin & vegetarian groups possibly they were consuming undercooked, infected meat. Most of the Hindu, Brahmin, vegetarian groups do not take non-veg food more so pork’s meat. Brahmin, vegetarians were equally predisposed to the infestation as, non-brahmin who consume pork, may be due to deculturation, change of pattern of food habit, using contaminated green vegetable, water or poor personal hygiene

In this series of study, majority of cases 56% were diagnosed above 2 years of onset of symptoms, few were diagnosed even after 20 years of onset illness, it may be due to pleomorphic Neuropsychiatric manifestation, lack of proper investigatory tools as C.T. scanner or M.R.I. technique, underrating by general physician & surgeons, physical etiopathogenesis as a possible basis for mental symptoms accounts for missed or under diagnosis or late identification of cases. It may be also due to lack of mental health consciousness & superstitious belief for N.C.C. is rapidly increasing in our society. Still it could not be used commonly because of its price value.

The main clinical manifestation of N.C.C. in this study was seizure 79(94%), head ache 45(53.5%), mental deterioration 17 (20.2%) & depression 13(15.4%). N.C.C. should be considered in the presence of above symptoms in the individual from endemic area. This finding agrees with the report of Venkataraman et al, Medina & Gonzalo et al 1990.Among three types of seizures, generalized seizures 50(63.29%) were more higher than partial & unilateral seizures. They had mostly Solitary Parenchymal lesion, Multiple Parenchymal lesions & Extra Parenchymal lesions with hydrocephalous. Seizures without any other active lesions indicate increase intracranial pressure, hydrocephalous, cerebral edema & underlying irritating foci.

In this study, Neuropsychiatric manifestation was earliest symptoms & severe enough to dominate the picture. Lack of Neurological deficit, complex mental pictures like depression, anxiety, suicidal attempt, manic features associated with violent behavior, somatisation as headache in N.C.C. complicated for the earliest diagnosis. Affective disorder, psychotic & behavioral problem equally hard to evaluate with regard to the etiological role of the space occupying lesions & its location. Those cases had mainly Parietal, Frontal Parenchymal N.C.C. lesions. The clinicopathological correlation that emerge tend to be imprecise. It is hard to disentangle the effects, generalized effects of N.C.C. lesions. A good deal is contradictory from one report to another but certain mental symptoms emerged repeatedly representing the lesions, which can be the diagnostic important.

Neurological deficit which appeared only after the post ictal period was first to disappear after a few weeks, predominantly the neurological deficits were facial palsy, hemiplegia, diplopia, visual disturbances, in the background of mental symptoms. Fronto parietal lobe & intra ventricular lesions were most common in this study, correlated with neurological deficit. Prominent earliest appearance of mental symptoms & puzzling & unconvincing nature of neurological deficit appearing only after post ictal period readily invites to label functional psychiatric condition & might have delayed the diagnosis of N.C.C. Significance mental deterioration were recorded in this study which reflects the underlying irritating lesions, cortical atrophy, cerebral edema, hydrocephalous which were resulted by the parasite. MMSE tools used to evaluate cognitive functioning revealed the improved performance by Single Parenchymal N.C.C. in contrast to Multiple & Extra Parenchymal N.C.C. after treatment which can be used for evaluating the prognosis of the patients. In an early stage patients had shown significance deterioration of I.Q. due to cortical atrophy, neuronal damage & hydrocephalous. The improvement of I.Q. was significance after ABZ therapy.

Standard plan for the management of N.C.C. with cysticides is yet debatable but this study revealed that therapeutic efficacy of ABZ with oral cortisone was more effective & least toxic in the various types of N.C.C. agrees with the findings of Alarcon et al 1990. The cure & resolution rate of cerebral lesions with ABZ was 100% is documented by Brutto et al 1990. As per the therapeutic responses with ABZ the N.C.C. may be classified into three groups (a) Solitary Benign Parenchymal & (b) Multiple Benign Parenchymal were relatively simple to treat with ABZ, cortisone & anti convulsant therapy in contrast to (c) Malignant Extra Parenchymal & complicated form of N.C.C.

CONCLUSION: -