Submit Search
Upload
AAN Guideline for Treatment of Neurocysticercosis
•
Download as PPT, PDF
•
0 likes
•
20 views
AI-enhanced title
I
IndhujaKarunakaran2
Follow
parenchymal neurocysticercosis
Read less
Read more
Health & Medicine
Report
Share
Report
Share
1 of 41
Download now
Recommended
The Diagnostic Evaluation and Treatment of Trigeminal Neuralgia.ppt
The Diagnostic Evaluation and Treatment of Trigeminal Neuralgia.ppt
Kollanur Charan
HLinc presentation: levels of evidence
HLinc presentation: levels of evidence
CatherineVoutier
OBSERVATIONAL STUDIES PPT.pptx
OBSERVATIONAL STUDIES PPT.pptx
KrishnaveniManubolu
Excelsior College PBH 321 Page 1 EXPERI MENTAL E.docx
Excelsior College PBH 321 Page 1 EXPERI MENTAL E.docx
gitagrimston
study design of clinical research
study design of clinical research
MD Jahidul Islam
biostatists presentation
biostatists presentation
Anil kumar
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
umfrfouda
Clinical research
Clinical research
MangeshBansod2
Recommended
The Diagnostic Evaluation and Treatment of Trigeminal Neuralgia.ppt
The Diagnostic Evaluation and Treatment of Trigeminal Neuralgia.ppt
Kollanur Charan
HLinc presentation: levels of evidence
HLinc presentation: levels of evidence
CatherineVoutier
OBSERVATIONAL STUDIES PPT.pptx
OBSERVATIONAL STUDIES PPT.pptx
KrishnaveniManubolu
Excelsior College PBH 321 Page 1 EXPERI MENTAL E.docx
Excelsior College PBH 321 Page 1 EXPERI MENTAL E.docx
gitagrimston
study design of clinical research
study design of clinical research
MD Jahidul Islam
biostatists presentation
biostatists presentation
Anil kumar
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
umfrfouda
Clinical research
Clinical research
MangeshBansod2
Epidemiology designs for clinical trials - Pubrica
Epidemiology designs for clinical trials - Pubrica
Pubrica
Introduction to N-of-1 Trials_ Indications and Barriers (Chapter 1) _ Effecti...
Introduction to N-of-1 Trials_ Indications and Barriers (Chapter 1) _ Effecti...
agumas6
Bias in clinical research
Bias in clinical research
sathyanarayanan varadarajan
Research methodology part 1
Research methodology part 1
DrGayatriMehrotra
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled Trials
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled Trials
Lisa Graves
clinical trials types and design
clinical trials types and design
Uttara Joshi
An overview of clinical research the lay of the land
An overview of clinical research the lay of the land
Efrain Ariel Romero Zepeda
randomised controlled trial
randomised controlled trial
DrSridevi NH
Writing the research protocol part 2- Methodology-Dr. Yasser Mohammed Hassana...
Writing the research protocol part 2- Methodology-Dr. Yasser Mohammed Hassana...
YasserMohammedHassan1
Hepatitis Autoinmune .PDF - Medicina Interna II
Hepatitis Autoinmune .PDF - Medicina Interna II
Matias Fernandez Viña
Running head CRITIQUE QUANTITATIVE, QUALITATIVE, OR MIXED METHODS.docx
Running head CRITIQUE QUANTITATIVE, QUALITATIVE, OR MIXED METHODS.docx
todd271
Clinical trials
Clinical trials
AmarRaj28
Clinical research (study designs)
Clinical research (study designs)
Mohamed Fahmy Dehim
Research methodology
Research methodology
Dr Alok Mishra
Research methodology
Research methodology
Dr Alok Mishra
OVERVIEW OF RESEARCH DESIGN IN EDUCATION
OVERVIEW OF RESEARCH DESIGN IN EDUCATION
AmsyarDaud1
Clinical trial : Types and Design (Pharmacovigilance)
Clinical trial : Types and Design (Pharmacovigilance)
Ayush Roy
community dentistry lecture 4
community dentistry lecture 4
NoorahMurad
Lec 3 (2019)
Lec 3 (2019)
NoorahMurad
Clinical Study Design and Methods Terminology
Clinical Study Design and Methods Terminology
MadhukarSureshThagna
cardiac hypertrophy
cardiac hypertrophy
IndhujaKarunakaran2
ALTEPLASE.pptx
ALTEPLASE.pptx
IndhujaKarunakaran2
More Related Content
Similar to AAN Guideline for Treatment of Neurocysticercosis
Epidemiology designs for clinical trials - Pubrica
Epidemiology designs for clinical trials - Pubrica
Pubrica
Introduction to N-of-1 Trials_ Indications and Barriers (Chapter 1) _ Effecti...
Introduction to N-of-1 Trials_ Indications and Barriers (Chapter 1) _ Effecti...
agumas6
Bias in clinical research
Bias in clinical research
sathyanarayanan varadarajan
Research methodology part 1
Research methodology part 1
DrGayatriMehrotra
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled Trials
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled Trials
Lisa Graves
clinical trials types and design
clinical trials types and design
Uttara Joshi
An overview of clinical research the lay of the land
An overview of clinical research the lay of the land
Efrain Ariel Romero Zepeda
randomised controlled trial
randomised controlled trial
DrSridevi NH
Writing the research protocol part 2- Methodology-Dr. Yasser Mohammed Hassana...
Writing the research protocol part 2- Methodology-Dr. Yasser Mohammed Hassana...
YasserMohammedHassan1
Hepatitis Autoinmune .PDF - Medicina Interna II
Hepatitis Autoinmune .PDF - Medicina Interna II
Matias Fernandez Viña
Running head CRITIQUE QUANTITATIVE, QUALITATIVE, OR MIXED METHODS.docx
Running head CRITIQUE QUANTITATIVE, QUALITATIVE, OR MIXED METHODS.docx
todd271
Clinical trials
Clinical trials
AmarRaj28
Clinical research (study designs)
Clinical research (study designs)
Mohamed Fahmy Dehim
Research methodology
Research methodology
Dr Alok Mishra
Research methodology
Research methodology
Dr Alok Mishra
OVERVIEW OF RESEARCH DESIGN IN EDUCATION
OVERVIEW OF RESEARCH DESIGN IN EDUCATION
AmsyarDaud1
Clinical trial : Types and Design (Pharmacovigilance)
Clinical trial : Types and Design (Pharmacovigilance)
Ayush Roy
community dentistry lecture 4
community dentistry lecture 4
NoorahMurad
Lec 3 (2019)
Lec 3 (2019)
NoorahMurad
Clinical Study Design and Methods Terminology
Clinical Study Design and Methods Terminology
MadhukarSureshThagna
Similar to AAN Guideline for Treatment of Neurocysticercosis
(20)
Epidemiology designs for clinical trials - Pubrica
Epidemiology designs for clinical trials - Pubrica
Introduction to N-of-1 Trials_ Indications and Barriers (Chapter 1) _ Effecti...
Introduction to N-of-1 Trials_ Indications and Barriers (Chapter 1) _ Effecti...
Bias in clinical research
Bias in clinical research
Research methodology part 1
Research methodology part 1
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled Trials
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled Trials
clinical trials types and design
clinical trials types and design
An overview of clinical research the lay of the land
An overview of clinical research the lay of the land
randomised controlled trial
randomised controlled trial
Writing the research protocol part 2- Methodology-Dr. Yasser Mohammed Hassana...
Writing the research protocol part 2- Methodology-Dr. Yasser Mohammed Hassana...
Hepatitis Autoinmune .PDF - Medicina Interna II
Hepatitis Autoinmune .PDF - Medicina Interna II
Running head CRITIQUE QUANTITATIVE, QUALITATIVE, OR MIXED METHODS.docx
Running head CRITIQUE QUANTITATIVE, QUALITATIVE, OR MIXED METHODS.docx
Clinical trials
Clinical trials
Clinical research (study designs)
Clinical research (study designs)
Research methodology
Research methodology
Research methodology
Research methodology
OVERVIEW OF RESEARCH DESIGN IN EDUCATION
OVERVIEW OF RESEARCH DESIGN IN EDUCATION
Clinical trial : Types and Design (Pharmacovigilance)
Clinical trial : Types and Design (Pharmacovigilance)
community dentistry lecture 4
community dentistry lecture 4
Lec 3 (2019)
Lec 3 (2019)
Clinical Study Design and Methods Terminology
Clinical Study Design and Methods Terminology
More from IndhujaKarunakaran2
cardiac hypertrophy
cardiac hypertrophy
IndhujaKarunakaran2
ALTEPLASE.pptx
ALTEPLASE.pptx
IndhujaKarunakaran2
COPD ppt.pptx
COPD ppt.pptx
IndhujaKarunakaran2
NEWBORN CASE PRESENTATION (2).pptx
NEWBORN CASE PRESENTATION (2).pptx
IndhujaKarunakaran2
MUSCLE TONE.pptx
MUSCLE TONE.pptx
IndhujaKarunakaran2
neonatal reflexes case presentation.pptx
neonatal reflexes case presentation.pptx
IndhujaKarunakaran2
resp_nbrn.ppt
resp_nbrn.ppt
IndhujaKarunakaran2
TWINS PRESENTATION.pptx
TWINS PRESENTATION.pptx
IndhujaKarunakaran2
HIE.pptx
HIE.pptx
IndhujaKarunakaran2
NEWBORN CASE PRESENTATION.pptx
NEWBORN CASE PRESENTATION.pptx
IndhujaKarunakaran2
More from IndhujaKarunakaran2
(10)
cardiac hypertrophy
cardiac hypertrophy
ALTEPLASE.pptx
ALTEPLASE.pptx
COPD ppt.pptx
COPD ppt.pptx
NEWBORN CASE PRESENTATION (2).pptx
NEWBORN CASE PRESENTATION (2).pptx
MUSCLE TONE.pptx
MUSCLE TONE.pptx
neonatal reflexes case presentation.pptx
neonatal reflexes case presentation.pptx
resp_nbrn.ppt
resp_nbrn.ppt
TWINS PRESENTATION.pptx
TWINS PRESENTATION.pptx
HIE.pptx
HIE.pptx
NEWBORN CASE PRESENTATION.pptx
NEWBORN CASE PRESENTATION.pptx
Recently uploaded
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
narwatsonia7
Call Girl Bangalore Nandini 7001305949 Independent Escort Service Bangalore
Call Girl Bangalore Nandini 7001305949 Independent Escort Service Bangalore
narwatsonia7
Call Girls Budhwar Peth 7001305949 All Area Service COD available Any Time
Call Girls Budhwar Peth 7001305949 All Area Service COD available Any Time
vijaych2041
Bangalore Call Girls Majestic 📞 9907093804 High Profile Service 100% Safe
Bangalore Call Girls Majestic 📞 9907093804 High Profile Service 100% Safe
narwatsonia7
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
narwatsonia7
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
sonalikaur4
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
narwatsonia7
Low Rate Call Girls Pune Esha 9907093804 Short 1500 Night 6000 Best call girl...
Low Rate Call Girls Pune Esha 9907093804 Short 1500 Night 6000 Best call girl...
Miss joya
Escort Service Call Girls In Sarita Vihar,, 99530°56974 Delhi NCR
Escort Service Call Girls In Sarita Vihar,, 99530°56974 Delhi NCR
9953056974 Low Rate Call Girls In Saket, Delhi NCR
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
narwatsonia7
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
narwatsonia7
Russian Call Girl Brookfield - 7001305949 Escorts Service 50% Off with Cash O...
Russian Call Girl Brookfield - 7001305949 Escorts Service 50% Off with Cash O...
narwatsonia7
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
MedicoseAcademics
sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
9953056974 Low Rate Call Girls In Saket, Delhi NCR
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
Nehru place Escorts
Vip Call Girls Anna Salai Chennai 👉 8250192130 ❣️💯 Top Class Girls Available
Vip Call Girls Anna Salai Chennai 👉 8250192130 ❣️💯 Top Class Girls Available
Nehru place Escorts
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
narwatsonia7
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Nehru place Escorts
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
narwatsonia7
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
narwatsonia7
Recently uploaded
(20)
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girl Bangalore Nandini 7001305949 Independent Escort Service Bangalore
Call Girl Bangalore Nandini 7001305949 Independent Escort Service Bangalore
Call Girls Budhwar Peth 7001305949 All Area Service COD available Any Time
Call Girls Budhwar Peth 7001305949 All Area Service COD available Any Time
Bangalore Call Girls Majestic 📞 9907093804 High Profile Service 100% Safe
Bangalore Call Girls Majestic 📞 9907093804 High Profile Service 100% Safe
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Low Rate Call Girls Pune Esha 9907093804 Short 1500 Night 6000 Best call girl...
Low Rate Call Girls Pune Esha 9907093804 Short 1500 Night 6000 Best call girl...
Escort Service Call Girls In Sarita Vihar,, 99530°56974 Delhi NCR
Escort Service Call Girls In Sarita Vihar,, 99530°56974 Delhi NCR
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Russian Call Girl Brookfield - 7001305949 Escorts Service 50% Off with Cash O...
Russian Call Girl Brookfield - 7001305949 Escorts Service 50% Off with Cash O...
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
Vip Call Girls Anna Salai Chennai 👉 8250192130 ❣️💯 Top Class Girls Available
Vip Call Girls Anna Salai Chennai 👉 8250192130 ❣️💯 Top Class Girls Available
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
Call Girl Service Bidadi - For 7001305949 Cheap & Best with original Photos
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
AAN Guideline for Treatment of Neurocysticercosis
1.
©2013 American Academy
of Neurology Evidence-based Guideline: Treatment of Parenchymal Neurocysticercosis Report of the Guideline Development Subcommittee of theAmerican Academy of Neurology
2.
©2013 American Academy
of Neurology This guideline is endorsed by the American Epilepsy Society. Guideline Endorsement
3.
©2013 American Academy
of Neurology Authors Ruth Ann Baird, MD Sam Wiebe, MD Joseph R. Zunt, MD, MPH John J. Halperin, MD, FAAN Gary Gronseth, MD, FAAN Karen L. Roos, MD, FAAN
4.
©2013 American Academy
of Neurology Sharing this information The AAN develops these presentation slides as educational tools for neurologists and other health care practitioners. You may download and retain a single copy for your personal use. Please contact guidelines@aan.com to learn about options for sharing this content beyond your personal use.
5.
©2013 American Academy
of Neurology Presentation Objectives To present the review of the evidence base for different treatment strategies in intraparenchymal neurocysticercosis in adults and children To present evidence-based recommendations
6.
©2013 American Academy
of Neurology Overview Background Gaps in care American Academy of Neurology (AAN) guideline process Analysis of evidence, conclusions, recommendations Recommendations for future research
7.
©2013 American Academy
of Neurology Background Cysticercosis, infection with the larval form of Taenia solium, is widely prevalent in developing countries of Africa, Asia, and Latin America. • Considered by the World Health Organization (WHO) to be the most common preventable cause of epilepsy in the developing world, with an estimated 2 million people having epilepsy caused by T. solium infection.1 Humans can acquire two different forms of infection—by eating raw or undercooked pork containing T. solium cysts or by eating food contaminated with T. solium eggs. • Cysts consumed in undercooked meat mature into adult parasites in the human intestine, at which time they release eggs and gravid proglottids in the stool. This form of intestinal infection is called taeniasis.
8.
©2013 American Academy
of Neurology Background, cont. When T. solium eggs are consumed, through fecal–oral transmission from another human with taeniasis or through autoinfection, they release oncospheres into the host’s digestive tract and can then migrate throughout the host’s body, becoming encysted in end organs. This systemic infection is called cysticercosis. Seeding of larvae in the CNS results in neurocysticercosis. Neurocysticercosis, in turn, may affect the CNS parenchyma or the CSF space.
9.
©2013 American Academy
of Neurology Background, cont. This guideline focuses solely on parenchymal infections. Optimal treatment of this infection has been the subject of considerable debate, with controversy regarding the appropriate role of both corticosteroids and cysticidal drugs such as praziquantel or albendazole for active infections.
10.
©2013 American Academy
of Neurology AAN Guideline Process Clinical Question Evidence Conclusions Recommendations
11.
©2013 American Academy
of Neurology Clinical Questions In patients with symptomatic intraparenchymal neurocysticercosis, is cysticidal therapy more effective than no therapy, and does it affect long- term seizure outcome? In patients with symptomatic intraparenchymal neurocysticercosis, is treatment with corticosteroids more effective than no treatment? When during the course of antiparasitic treatment should steroids be started?
12.
©2013 American Academy
of Neurology Clinical Questions, cont. What is the efficacy of antiepileptic drugs (AEDs) in treating or decreasing occurrence of subsequent seizures secondary to intraparenchymal neurocysticercosis, and what is the optimal time course of AED treatment for seizures secondary to intraparenchymal neurocysticercosis?
13.
©2013 American Academy
of Neurology Literature Search/Review Rigorous, Comprehensive, Transparent Review abstracts Search Review full text Select articles Relevant Search
14.
©2013 American Academy
of Neurology AAN Classification of Evidence All studies meeting inclusion/exclusion criteria defined a priori rated Class I, II, III, or IV Five different classification systems • Therapeutic Randomization, control, blinding • Diagnostic Comparison with reference standard • Prognostic • Screening • Causation
15.
©2013 American Academy
of Neurology AAN Level of Recommendations A = Established as effective, ineffective or harmful (or established as useful/predictive or not useful/predictive) for the given condition in the specified population B = Probably effective, ineffective or harmful (or probably useful/predictive or not useful/predictive) for the given condition in the specified population C = Possibly effective, ineffective or harmful (or possibly useful/predictive or not useful/predictive) for the given condition in the specified population U = Data inadequate or conflicting; given current knowledge, treatment (test, predictor) is unproven Note that recommendations can be positive or negative
16.
©2013 American Academy
of Neurology Translating Class to Recommendations A = Requires at least two consistent Class I studies* B = Requires at least one Class I study or two consistent Class II studies C = Requires at least one Class II study or two consistent Class III studies U = Assigned in cases of only one Class III study, only Class IV studies, or evidence that is conflicting and cannot be reconciled * In exceptional cases, one convincingClass I study may sufficefor an “A” recommendation if 1) allcriteria are met, 2) the magnitudeof effect is large (relative rate improved outcome >5 and the lower limitof the confidence interval is >2).
17.
©2013 American Academy
of Neurology Applying the Process to the Issue We will now turn our attention to the guideline.
18.
©2013 American Academy
of Neurology Methods MEDLINE, EMBASE, LILACS and Cochrane Database of Systematic Reviews and Controlled Clinical trials were searched. • 1980 to 2008, updated in 2012 Authors reviewed each article for inclusion. Risk of bias was determined using the classification of evidence scheme for therapeutic articles. Strength of recommendations was linked directly to evidence levels. Resulted in 10 Class I or Class II trials of cysticidal drugs administered with or without corticosteroids in the treatment of neurocysticercosis Conflicts of interest were disclosed.
19.
©2013 American Academy
of Neurology Literature Search/Review Rigorous, Comprehensive, Transparent 123 articles 610 abstracts Inclusion criteria: - Randomized, controlled trials; cohort studies; case- control studies; case series (n ≥20); review articles; meta-analyses Exclusion criteria: - Case reports, small case series (n <20), review articles without primary data - Articles in languages other than English or Spanish - Animal studies
20.
©2013 American Academy
of Neurology AAN Classification of Evidence for Therapeutic Intervention Class I: A randomized, controlled clinical trial of the intervention of interest with masked or objective outcome assessment, in a representative population. Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences. The following are also required: • Concealed allocation • Primary outcome(s) clearly defined • Exclusion/inclusion criteria clearly defined • Adequate accounting for dropouts (with at least 80% of enrolled subjects completing the study) and crossovers with numbers sufficiently low to have minimal potential for bias.
21.
©2013 American Academy
of Neurology AAN Classification of Evidence for Therapeutic Intervention, cont. • For noninferiority or equivalence trials claiming to prove efficacy for one or both drugs, the following are also required*: The authors explicitly state the clinically meaningful difference to be excluded by defining the threshold for equivalence or noninferiority. The standard treatment used in the study is substantially similar to that used in previous studies establishing efficacy of the standard treatment (e.g., for a drug, the mode of administration, dose and dosage adjustments are similar to those previously shown to be effective). The inclusion and exclusion criteria for patient selection and the outcomes of patients on the standard treatment are comparable to those of previous studies establishing efficacy of the standard treatment. The interpretation of the results of the study is based upon a per protocol analysis that takes into account dropouts or crossovers.
22.
©2013 American Academy
of Neurology AAN Classification of Evidence for Therapeutic Intervention, cont. Class II: A randomized controlled clinical trial of the intervention of interest in a representative population with masked or objective outcome assessment that lacks one criteria ae above or a prospective matched cohort study with masked or objective outcome assessment in a representative population that meets be above. Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences. Class III: All other controlled trials (including well-defined natural history controls or patients serving as own controls) in a representative population, where outcome is independently assessed, or independently derived by objective outcome measurement.**
23.
©2013 American Academy
of Neurology AAN Classification of Evidence for Therapeutic Intervention, cont. Class IV: Studies not meeting Class I, II, or III criteria including consensus or expert opinion. *Note that numbers 13 in Class I, item 5 are required for Class II in equivalence trials. If any one of the three is missing, the class is automatically downgraded to Class III. **Objective outcome measurement: an outcome measure that is unlikely to be affected by an observer’s (patient, treating physician, investigator) expectation or bias (e.g., blood tests, administrative outcome data).
24.
©2013 American Academy
of Neurology Clinical Question 1 In patients with symptomatic intraparenchymal neurocysticercosis, is cysticidal therapy more effective than no therapy, and does it affect long- term seizure outcome?
25.
©2013 American Academy
of Neurology Based on imaging findings in 4 Class I studies (3 concordant, 1 underpowered study failing to show an effect) and a meta-analysis of 2 Class I and 4 Class II studies, albendazole (400 mg BID for adults or weight-based dosing for either adults or children) is probably safe and effective in reducing both the number of cysts and long-term seizure frequency in adults and children with neurocysticercosis. In most studies, corticosteroids were coadministered, in varying dosages, and this combination appears effective. Data are insufficient to indicate whether corticosteroids are necessary in this setting. Cysticidal Therapy: Conclusion
26.
©2013 American Academy
of Neurology Clinical Context The available studies have used different stratification methods for seizure analysis and different criteria for judging improvement in imaging. On the basis of the 3 Class I studies it appears albendazole plus corticosteroids decreases the number of active brain lesions relative to placebo and, on the basis of a meta-analysis of available data, decreases the number of patients with seizures, at modest cost. These findings appear to be consistent in adults and children. Side effects of treatment appear minimal. Of greatest concern has been the potential — emphasized in a single large study2 — for increased seizures and encephalopathy as a result of treatment-induced parasite death.
27.
©2013 American Academy
of Neurology Clinical Context, cont. Recommendations often emphasize the danger of antihelminthic treatment in patients with a very large lesion burden. The cited studies all excluded patients with massive cerebral edema or innumerable lesions but were otherwise inconsistent. Three studies3–5 were limited to patients with single lesions. In one study, patients had 1 or 2 cysts.6 In another study, 84% of patients had 1 or 2; the remainder had fewer than 100. In the remaining 3 studies, the number of cysts was described as “multiple,”7 “less than 20,”8 and “less than 36.”9
28.
©2013 American Academy
of Neurology Cysticidal Therapy: Recommendation Albendazole plus either dexamethasone or prednisolone should be considered for adults and children with neurocysticercosis, both to decrease the number of active lesions on brain- imaging studies (Level B) and to reduce long-term seizure frequency (Level B).
29.
©2013 American Academy
of Neurology Clinical Question 2 In patients with symptomatic intraparenchymal neurocysticercosis, is treatment with corticosteroids more effective than no treatment?
30.
©2013 American Academy
of Neurology Corticosteroids: Conclusion On the basis of one Class I study showing no benefit radiologically and ambiguous benefit clinically and one Class II/IV study showing benefit, there is insufficient evidence to recommend steroid treatment alone for patients with solitary intraparenchymal neurocysticercosis.
31.
©2013 American Academy
of Neurology Clinical Context The effect of corticosteroid treatment alone in neurocysticercosis has not been widely studied. Most trials include a combination of cysticidal therapy and steroid treatment.
32.
©2013 American Academy
of Neurology Corticosteroids: Recommendation The evidence is insufficient to support or refute the use of steroid treatment alone in patients with intraparenchymal neurocysticercosis (Level U).
33.
©2013 American Academy
of Neurology Clinical Question 3 When during the course of antiparasitic treatment should steroids be started? We found no studies to answer this question.
34.
©2013 American Academy
of Neurology Clinical Question 4 What is the efficacy of AEDs in treating or decreasing occurrence of subsequent seizures secondary to intraparenchymal neurocysticercosis, and what is the optimal time course of AED treatment for seizures secondary to intraparenchymal neurocysticercosis? We found no studies to answer this question.
35.
©2013 American Academy
of Neurology Clinical Context Given the well-established efficacy and safety of a broad range of AEDs and the frequency with which neurocysticercosis causes seizures, it is reasonable to treat these patients with AEDs at least until the active lesions have subsided.
36.
©2013 American Academy
of Neurology Future Research Recommendations Several aspects of treatment require further study: Cysticercal cysts evolve through four stages: the living larva, the degenerating larva, a reactive thickening of the cyst membrane, and calcification. Only cysts in the first two stages contain live cysts.10 A study that evaluates the response to therapy on the basis of the stage of the cyst would be useful. The successful treatment trials cited all used cysticidal therapy administered with or without corticosteroids. Studies are needed to determine the appropriate use and timing of administration of adjuvant corticosteroids and the potential benefit of combination cysticidal therapy.
37.
©2013 American Academy
of Neurology Future Research Recommendations, cont. Neurocysticercosis can be intraventricular or intraocular or can involve the subarachnoid space. Studies have not addressed these forms of the infection. Assessment of different treatment strategies, medical or surgical, for such patients would be helpful. HIV coinfection may alter efficacy of antihelminthic treatment or produce important drug–drug interactions; determination of best treatment for neurocysticercosis in such patients is needed. Additional studies should focus on clinical outcomes rather than surrogate CT outcomes, as the two do not always correlate. Patients may experience seizure recurrence despite resolution of lesions on CT.
38.
©2013 American Academy
of Neurology References 1. Coyle CM, Mahanty S, Zunt JR, et al. Neurocysticercosis: Neglected but not forgotten. PLoS neglected tropical diseases 2012;5:e1500. 2. Das K, Mondal GP, Banerjee M, Mukherjee BB, Singh OP. Role of antiparasitic therapy for seizures and resolution of lesions in neurocysticercosis patients: An 8 year randomised study. J Clin Neurosci 2007;14:1172–1177. 3. Chaurasia RN, Garg RK, Agarwal A, et al. Three day albendazole therapy in patients with a solitary cysticercus granuloma: a randomized double blind placebo controlled study. Southeast Asian J Trop Med Public Health 2010;41:517–525. 4. Baranwal AK, Singhi PD, Khandelwal N, Singhi SC. Albendazole therapy in children with focal seizures and single small enhancing computerized tomographic lesions: a randomized, placebo-controlled, double blind trial. Pediatr Infect Dis J 1998;17:696–700. 5. Singhi P, Jain V, Khandelwal N. Corticosteroids versus albendazole for treatment of single small enhancing computed tomographic lesions in children with neurocysticercosis. J Child Neurol 2004;19:323–327. 6. Kalra VK, Dua T, Kumar V. Efficacy of albendazole and short-course dexamethasone treatment in children with 1 or 2 ring-enhancing lesions of neurocysticercosis: a randomized controlled trial. J Pediatr 2003;143:111–114.
39.
©2013 American Academy
of Neurology References, cont. 7. Padma MV, Behari M, Misra NK, Ahuja GK. Albendazole in neurocysticercosis. Natl Med J India 1995;8:255–258. 8. Garcia HH, Pretell EJ, Gilman RH, et al. A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis. N Engl J Med 2004;350:249–258. 9. Carpio A, Kelvin EA, Bagiella E, et al. Effects of albendazole treatment on neurocysticercosis: a randomised controlled trial. J Neurol Neurosurg Psychiatry 2008;79:1050–1055. 10.Murthy JMK, Reddy YVS. Prognosis of epilepsy associated with single CT enhancing lesion: a long term followup study. J Neurol Sci 1998;159:151–155. For a complete list of references, please access the full guideline at www.aan.com/guidelines.
40.
©2013 American Academy
of Neurology Questions/comments? Question-and-Answer Period
41.
©2013 American Academy
of Neurology To access the complete guideline and related guideline summary tools, visit www.aan.com/guidelines. Thank you for your participation! Closing
Download now