Management

• Antimicrobial therapy with albendazole (15 mg/kg/day for 1 week to 1 month depending on severity of the disease) and praziquantel (usually 50 mg/kg/day for 15 days)
  
• Patients with cysticercotic encephalitis should not be presurgically treated with cysticidal drugs because this might exacerbate the intracranial hypertension; patients with both hydrocephalus and intracranial cysts should only receive cysticidal drugs after a ventricular shunt has been placed to avoid further increases of intracranial pressure as a result of drug therapy.
  
• High dose corticosteroids are the primary form of therapy for cysticercotic encephalitis, angiitis, and arachnoiditis causing progressive entrapment of cranial nerves.
  
• Concurrent use of corticosteroids with cysticidal drugs ameliorate the secondary effects of the cysticidal activity and help in avoiding cerebral infarction, acute hydrocephalus, spinal cord swelling, and massive brain edema.
  
• Epilepsy is the most common clinical manifestation–use of single antiepileptic agent usually results in seizure control in most patients.

Operative Planning

• Review imaging–magnetic resonance imaging (MRI) is study of choice, computed tomography shows end-stage calcified disease

Special Equipment

• MRI-guided navigation for stereotactic needle biopsy/aspiration or craniotomy for surgical resection
  
• Endoscope for intraventricular cystic aspiration or surgical resection of ventricular cysts

Positioning

• Varies depending on location of targeted cyst and type of surgery planned

Stereotactic Cyst Aspiration

• Advantages: less invasive than open craniotomy with decreased operating and anesthesia time
  
• Disadvantages: cyst wall remains, inability to remove entire lesion
  
• Aspiration directed toward largest and most symptomatic cysts, targeting cyst center
  
• If possible, avoid eloquent cortex and ventricle
  
• Following aspiration, consider leaving indwelling cyst catheter-reservoir for repeated cyst aspiration, especially for recurrent, complex cysts

Open Craniotomy

• Advantages: can attempt cyst wall removal without rupture, and can often completely remove entire cystic components
  
• Disadvantages: longer and more invasive procedure compared with stereotactic aspiration
  
• Positioning and craniotomy site and size need to allow for access to multiple cysts if applicable
  
• Lateral or third ventricular cysts: frontal craniotomy with transcortical or transcallosal approach, fenestration of septum pellucidum
  
• Fourth ventricular cysts: suboccipital craniectomy or craniotomy
  
• Endoscopic removal for some ventricular cysts

Ventricular Shunting

• Approximately one half of patients with intraventricular cysts and hydrocephalus will require shunting despite open cyst removal.
  
• Hydrocephalus may be obstructive from mass effect, or communicating via increased protein and impaired arachnoid granulations.
  
• Shunts frequently become obstructed while infection is still present or clearing. Consider subgaleal reservoir for future aspiration.

Spinal Decompression

• Spinal involvement is rare but cysts can cause direct spinal cord compression or secondary compression from bony collapse.
  
• Decompression based on location. See spinal chapters for specific approach techniques and indications for fusion.
  
• Goal of surgery is spinal cord decompression and cyst removal, if possible.