|Year : 2007 | Volume
| Issue : 1 | Page : 39-43
Evaluation of role of steroid alone and with albendazole in patients of epilepsy with single-small enhancing computerized tomography lesions
Shri Ram Sharma, Atul Agarwal, AM Kar, Rakesh Shukla, RK Garg
Department of Neurology, KG Medical University, Lucknow, India
Shri Ram Sharma
Department of Neurology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This study was planned to evaluate the role of steroid alone and with albendazole in patients of single-small enhancing computerized tomography (CT) lesions in Indian patients presenting with new-onset seizures. In this study, 95 patients with new onset seizures and a single enhancing CT lesion were randomly divided in two groups to receive either antiepileptic drug and steroid alone (n=42) or antiepileptic drug with a steroid and albendazole (n=48). These patients were prospectively followed-up for six months. Repeat CT scans were performed after 30 days and six months of registration. The majority of patients were below 30 years of age. Simple partial seizure, with or without secondary generalization, was the commonest type of seizure encountered in these patients. Follow-up CT scans, after one month of registration showed complete disappearance of lesion in 16.7% of patients in Group I and in 25% of patients in Group II (χ2 =0.93, P =0.334). Follow-up CT scans, after six months of registration showed complete disappearance of lesion in 59.5% of patients in Group I and in 68.8% of patients in Group II (χ2=0.83, P =0.362). During the six months follow-up five patients (11.8%) in Group I and nine patients (18.7%) in Group II experienced seizures recurrence. Two patients in Group II experienced seizure recurrence despite complete disappearance of CT lesions. Seizure control and disappearance of lesion was same in both Groups. Albendazole does not seem to affect resolution.
Keywords: Albendazole, computed tomography, epilepsy, neurocysticercosis, outcome, steroid
|How to cite this article:|
Sharma S, Agarwal A, Kar A M, Shukla R, Garg R K. Evaluation of role of steroid alone and with albendazole in patients of epilepsy with single-small enhancing computerized tomography lesions. Ann Indian Acad Neurol 2007;10:39-43
|How to cite this URL:|
Sharma S, Agarwal A, Kar A M, Shukla R, Garg R K. Evaluation of role of steroid alone and with albendazole in patients of epilepsy with single-small enhancing computerized tomography lesions. Ann Indian Acad Neurol [serial online] 2007 [cited 2020 Oct 31];10:39-43. Available from: https://www.annalsofian.org/text.asp?2007/10/1/39/31484
Single enhancing computerized tomography (CT) lesions [Figure - 1] are a common imaging abnormality in Indian patients with new onset seizures.,,, Histopathological studies suggest that single enhancing CT lesions, in the majority of patients, represent dying cysticercus's larva. Another, less common, cause of these lesions are tuberculomas. Several retrospective studies have observed that these lesions resolve spontaneously., In several other studies,, these lesions have been treated with anticysticercal drugs, however with conflicting results. It is predominantly the acute inflammation and edema around these lesions that produces seizures. The objective of the present study was to compare the effect of steroid alone and with albendazole in these patients.
| Materials and Methods|| |
This prospective randomized study included 95 consecutive patients of new onset seizure disorder with a contrast CT scan showing ring/ disc-enhancing lesion. These patients were attending Neurology outdoor clinic of King George's Medical University, Lucknow, India between Dec 2002 to Jan 2004. All these patients presented within 14 days of onset of seizure disorder and were immediately (within 24 hours) subjected to plain and contrast CT scans. The patients selected fulfilled the clinical and radiological criteria suggestive of cysticercus granuloma [Table - 1].
Out of these, two patients were excluded further because of history of albendazole intake before registration, three were excluded because of history of albendazole intake during follow-up in group I (antiepileptic drug + steroid).
Nine patients lost follow-up in both group. Six patients in group 1 and three patients in group 2
Finally 81 patients completed the study. 36 patients in group I (antiepileptic drug + steroid) and 45 patients in group II (antiepileptic drug + steroid + albendazole).
Each selected patient was subjected to a detailed neurological examination. An eyewitness account of seizure episodes was obtained either from a relative or a friend. Seizures were classified as per the International League Against Epilepsy Classification of seizures types. From each patient, routine hematological and biochemical parameters were obtained.
In addition, enzyme linked immunosorbent (ELISA) for human immuno deficiency virus and chest X-ray were performed to exclude other possible causes of similar CT morphology e.g., toxoplasmosis, secondary metastasis. MRI brain was performed wherever indicated.
Treatment and follow up
All patients were randomly divided according to a randomization table in two groups. In all patients in Group I (n = 42) and Group II (n = 48) antiepileptic drugs and steroids (Prednisolone 1 mg/ Kg/day) were started immediately. Patients were given monotherapy and the antiepileptic drug administered was either carbamazepine or Phenytoin. Initial drug dosage was based on body weight. In situations of seizures recurrence and/ or respective antiepileptic drug (AED) toxicity, appropriate dosages adjustments were performed. Therapeutic drug monitoring of AED was not done. All the patients received anti epileptic drugs and prednisolone for 14 days followed by tapering over next three (25% reduction/day). All patients in Group II (n=48) also received albendazole in two divided doses of 15 mg/kg/day after two days of AEDs and steroids for 15 days.
Patients were followed-up at fortnightly intervals for the first two months and then, at interval of one month; patients were prospectively followed-up for a total of six months. Follow-up CT scans were performed in all patients after one month and six month of registration. Visual analysis was performed by an independent observer (radiologist not familiar with clinical course of patients). The lesion was considered 'persisting', if no change in the CT appearance of the lesion was noted. It was considered as 'regressing' if, on visual analysis, the amount of cerebral edema had reduced and/ or the morphology of the lesion had altered. The 'disappearance', of the lesion was considered when the follow-up CT scan did not show the lesion. The lesion was considered 'calcified' when a hyperdense lesion (> 100HU) was seen on a plain CT scan at the same place where the original enhancing lesion was situated.
The analysis was done using Chi-square statistics for categorical observations and t-test to compare continuous observations such as age of onset, average number of seizures and duration of illness. Chi-square was used to test the significance of differences in two groups. P value <0.05 was considered significant.
| Results|| |
There were 90 patients who fulfilled the inclusion criteria during the study period. The majority of patients (49.3%) were in second decade of life. The male and female ratio was 1.4: 1 [Table - 2]. Simple partial seizures with or without secondary generalization were the commonest type of seizures (68.8%) associated with single enhancing lesions [Table - 3]. In 28.4% of the patients seizures occurred in clusters (multiple seizures within 24 hours), 40.7% of patients reported recurrent seizures before the start of antiepileptic therapy [Table - 2]. In the first CT scan in approximately 67.9% of the patients, an enhancing eccentric dot like structure suggestive of scolex of cysticercus larva was also seen inside the ring lesion [Figure - 1].
Single enhancing CT lesions were more common in parietal region as seen in 52%, next common location was frontal 28.2%. In 14 patients, lesion were present in occipital region, all patients had occipital lobes seizures. 72.2% of patients had mild edema (restricted to the cerebral lobe involved). 23 patients (24.4%) had moderate edema (edema involving the adjacent cerebral lobe [Table - 4].
Follow-up CT scans performed one month after the registration showed complete disappearance of lesion in 16.7 of patients in Group I and in 25% of patients in Group II (χ 2= 0.93, P =0.334). Overall outcome after one month, in terms of disappearance, regression and persistence of lesion was same in Group II as compared to Group I [Table - 5].
Follow-up CT scan performed six months after registration showed complete disappearance of lesion in 59.5% of patients in Group I and in 68.8% of patients in Group II (χ 2=0.83, P =0.362). . Overall outcome, after six months, in terms of disappearance, regression, calcification and persistence of lesion was the same in Group II as compared to Group I [Table - 6]. Disappearance of lesion after one month and six months was the same in Group II as compared to Group I [Table - 7].
During the follow-up period of six months, five patients (11.8%) in Group I and only nine patients (18.7%) in Group II experienced seizure recurrence [Table - 8]. Two patients in Group II experienced seizure recurrence despite complete disappearance of CT lesions [Table - 8]. During six months of follow-up, adverse drug reaction in form of erythema multiforme minor was seen in five patients and Steven-Johnson syndrome in two patients. All these patients were on carbamazepine. Side effects because of use of prednisolone were observed in none of the patients. Albendazole group showed more headache and vomiting.
| Discussion|| |
In this study, we observed that single enhancing CT lesions frequently affected younger patients; these patients presented as acute new-onset seizure disorder. Simple partial seizure with or without secondary generalization is the commonest seizure type seen in these patients irrespective of location of CT lesions. Albendazole and prednisolone along with antiepileptic drug at the time of new onset seizures, does not seem to affect resolution of CT lesions.
In the brain, a cysticercal cyst passes through four stages in its natural evolution. In the 'vesicular' stage the viable cyst contains invaginated larva bathed in translucent fluid. The cyst is encapsulated and there is little tissue reaction. On CT the 'vesicular' form of cysticercosis appears as a non-enhancing lesion without edema. Eventually, in circumscribed and hypodense response to the host's immune reaction against the parasite the cyst shows hyaline degeneration and early mineralization. The cysts fluid changes to whitish, jelly-like material and the capsular membrane thickens. Inflammatory changes develop in the cyst wall and surrounding brain parenchyma. This 'colloidal' stage produces on CT a ring-enhancing lesion, initially with perilesional vasogenic edema. As the lesion continues to regress, the cyst size is reduced and the cyst membrane further thickens. The cyst contents are transformed into coarse granules, due to mineralization with calcium salt. This is the 'granular-nodular' stage, which is seen as a disc-enhancing lesion in CT scans. Ultimately, the cyst becomes completely mineralized- the 'calcified stage' - and a nodular hyperdense lesion is seen in noncontrast CT scans., Patients having a parenchymal cysticercal lesion become symptomatic when the cyst becomes acutely inflamed and this results in seizure clusters and frequent early recurrences. With resolution of inflammation in and around cystic lesions, the possibility of seizure recurrence also decreases.
There is enough evidence to suggest that anticysticercal drugs (praziquantel and albendazole are of value in the management of active parenchymal cerebral cysticercosis., However, there are conflicting views,, about the role of anticysticercal drugs in the management of single enhancing CT lesions. Mall et al . have demonstrated that steroid with Anti epileptic drug produce rapid resolution of lesions as well as better seizure control. However, no albendazole was given in that study. Prospective randomized studies on the role of steroid and albendazole are at best rare. Our study clearly suggests that albendazole dose not seen to affect the resolution of single enhancing CT lesions. Seizure recurrences were infrequent. However a large sample size study may be required to substantiate this study.
| Conclusion|| |
The observations from our study suggest that single enhancing CT lesions in patients with new-onset seizures, albendazole in dose of 15 mg/kg/day in two divided doses for 15 days did not seem to affect the resolution. Albendazole was not beneficial in management of SSECTL in our study.
| References|| |
|1.||Tandon PN, Bhargava, S. CNS tuberculosis lessons learnt from CT studies. Neurol India 1980;28:225-30. |
|2.||Rajshekhar V. Etiology and management of single small CT lesions inpatients with seizures: Understanding a controversy. Acta Neurol Scand 1991;84:465-70. [PUBMED] |
|3.||Chopa JS, Sawhney IM, Suresh N, Prabhakar N, Dhand UK, Suri S. Vanishing CT lesions in epilepsy. J Neurol Sci 1992;107:40-9. |
|4.||Garg RK, Nag D. Single ring- or disk-enhancing computed tomographic lesion in Indian children and adolescents after first seizure. Arch Pediatr Adolesc Med 1997;157:632-4. |
|5.||Rajshekhar V, Haran RP, Prakash GS, Chandy MJ. Differentiating solitary small cysticercus granulomas and tuberculomas in patients with epilepsy. Clinical and computerized tomographic criteria. J Neurosurg 1993;78:402-7. |
|6.||Sethi PK, Kumar BR, Madan VS, Mohan V. Appearing and disappearing CT scan abnormalities and seizures. J Neurol Neurosurg Psychiatry 1985;48:866-9. [PUBMED] |
|7.||Padma MV, Behari M, Misra NK, Ahuja GK. Albendazole in single CT ring lesions in epilepsy. Neurology 1994;44:1344-6. [PUBMED] |
|8.||Rajshekhar V. Albendazole therapy of persistent, solitary cysticercus granuloma in patients with seizure. Neurology 1993;43:1238-40. [PUBMED] |
|9.||Baranwal AK, Singhi PD, Khandelwal N, Singhi SC. Albendazole therapy in children with focal seizures and single small computed tomographic lesions. A randomized placebo-controlled, double blind trial. Peditr Infect Dis J 1998;17:696-700. |
|10.||Mall RK, Agarwal A, Garg RK, Kar AM, Shukla R. Short course of Prednisolone in Indian patients with solitary Cysticercus granuloma and new Onset seizures. Epilepsia 2003;44: 1397-401. [PUBMED] |
|11.||Rajshekhar V, Chandy MJ. Validation of diagnostic criteria for solitary cerebral cysticercus granuloma in patients presenting with seizures. Acta Neurologica Scandinavica 1997;96:76-81. [PUBMED] |
|12.||Escobar A. The pathology of neurocysticercosis. In : Cysticercosis of the central nervous system. Rodriguez-Carabazal E, Taveras JM, editors. CC Thomas: Springfield, IL; 1983. p. 27-54. |
|13.||Del Brutto OH, Sotelo J. Neurocysticercosis: An update. Rev Infect Dis 1988;10:1075-87. [PUBMED] |
|14.||Del Brutto OH. The use of albendazole in patients with single lesions enhanced on contrast CT. N Engl J Med 1993;328: 356-7. [PUBMED] |
|15.||Singhi P, Ray M, Singhi S, Khandelwal N. Clinical spectrum of 500 Children with neurocysticercosis and response to albendazole therapy. J Child Neurol 2000;15:207-13. [PUBMED] |
[Figure - 1]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8]
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