Browsing by Author "Carpio, Arturo"

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Albendazole therapy for subarachnoid cysticerci: clinical and neuroimaging analysis of 17 patients
(1999) Carpio, Arturo; Del Brutto, Oscar H.
y contrast with the weaknesses of anecdotal observations from case series, the power of randomised clinical trials for deciding the benefit of therapy has become increasingly evident and indisputable world wide. Nowadays, to argue against the validity of this assertion may seem superfluous; however, a recent paper reported by Del Brutto1 regarding treatment in neurocysticercosis ignores basic procedures for well performed clinical trials by using inappropriate and misleading methodology to evaluate medical therapy. By definition, a clinical trial is a prospective study comparing the effect and value of treatment against a control in human subjects. The main drawback of Del Brutto’s report is that it does not include a control group against which the intervention group is compared; therefore, its results are definitely flawed. Additionally, a basic experimental study design requires at least minimal information regarding inclusion and exclusion criteria, randomisation, and definitions of response or outcome variables. This information is not provided by Del Brutto’s report; its design fails to protect against potential bias in patient selection or evaluation of outcome. The definition of subarachnoid cysterci used by Del Brutto was based on “appearance on CT of hypodense cystic lesions located over the convexity of the cerebral hemispheres, the sylvian fissure, or the CSF cisterns at the base of the brain”. It is well known that there are many other diagnostic possibilities to be considered in the differential diagnosis of subarachnoid hypodense lesions.2 3 Besides, CT is not a reliable procedure for diagnosing subarachnoid cysterci, as is MRI. In fact, we cannot be completely sure, for example, that the CT images shown in the report of Del Brutto correspond to subarachnoid cysterci. If we were to use MRI on this patient, they might correspond to a parenchymal cyst which resolved as a reflection of the natural history of the condition. There is no evidence that objectively confirms or rejects this assertion.
Case-control study of seropositivity for cysticercosis in Cuenca, Ecuador
(1999) Goodman, K. A; Ballagh, S. A; Carpio, Arturo
The prevalence of neurocysticercosis has been well documented in rural communities in Latin America using the enzyme-linked inmmunoelectrotransfer blot (EITB) assay. We studied the prevalence of neurocysticercosis in an urban, upper-middle class population in Cuenca, Ecuador. Family members of 34 index cases with parenchymal neurocysticercosis on a computed tomography (CT) scan and family members of 14 patients who had normal CT scans after a trauma or migraine were enrolled in the study. Serum was obtained from 226 individuals, 173 (72%) from the case families and 67 (28%) from the control families. Twelve percent of the case family members and 4% of the control family members were seropositive by the EITB assay. This was a statistically significant difference (P , 0.05) when age and education were held constant by logistic regression. Seropositivity was not related to age. No neurologic symptom proved predictive of serostatus and the only demographic variable that correlated with seropositivity was increased crowding. Positive serology in index cases did correlate with CT findings as follows: 86% of patients with active lesions, 67% with transitional lesions, and only 41% of patients with inactive lesions were positive by the EITB assay. Eighteen percent of family members with a positive EITB test result had parenchymal lesions on a subsequent CT scan. This study demonstrates a high rate of seropositivity of cysticercosis among urban, middle to upper-middle class individuals in a region endemic for Taenia solium. Household contacts of patients with neurocysticercosis had a three-fold higher risk of positive serology for cysticercosis, in comparison with controls.
Chapter 72 Neurophysiological aspects of cerebral cysticercosis
(2002) Carpio, Arturo
Comment on epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE)
(2005-10) Beghi, Ettore; Carpio, Arturo; Berg, Anne; Forsgren, Lars; Hesdorffer, Dale C.; Hauser, W. Allen; Malmgren, Kristina; Shinnar, Shlomo; Temkin, Nancy; Thurman, David; Tomson, Torbjörn
Commentary
(2014-11) Carpio, Arturo
Cysticercosis and epilepsy: a critical review
(1998-10) Escobar, Alfonso; Hauser, W. Allen; Carpio, Arturo
Neurocysticercosis (NC) remains a major public health problem in developing and some developed countries. Currently, the best procedures for diagnosing NC are neuroimaging studies. Immunoserologic assays, such as enzyme-linked immunoelectrotransfer blot assay (EITB) or enzyme-linked immunosorbent assay (ELISA), detect antibodies against Taenia solium, or cysticercus. Consequently, they are useful in identifying a population at risk of contact with the parasite but do not necessarily indicate a systemic active infection. Most seropositive individuals are asymptomatic. No data from prospective studies concern the proportion of these individuals that will develop seizures or other neurologic symptoms. There is a discrepancy between the results of serologic assays and neuroimaging studies: >SO% of those individuals with NC diagnosed by computed tomography (CT) scan test EITB negative. Pathophysiologic classification of NC into active, transitional, and inactive forms permits a good correlation between clinical manifestations and neuroimaging procedures and facilitates medical and surgical management and research. The most frequent clinical manifestations of NC are seizures. We assume that NC is the main cause of symptomatic epilepsy in developing countries; however, no case-control or cohort studies demonstrate this association. Most patients with NC with seizures have a good prognosis; nevertheless, further studies analyzing factors related to recurrence of seizures and possibilities of discontinuation of antiepileptic medications (AEDs) are needed. Regarding treatment of NC with antihelminthic drugs, no controlled clinical trials exist that establish specific indications, definitive doses, and duration of treatment. The most effective approach to taeniasis/cysticercosis infection is prevention. This should be a primary public health focus for developing countries. We critically review the available information regarding the epidemiology and diagnosis of human cysticercosis, the physiopathology and imaging correlation of the parasite in the central nervous system (CNS) of the host, the relation between seizures or epilepsy and NC, and the issues surrounding the treatment and prognosis of NC, including the use of antihelminthic therapy.
Effects of albendazole treatment on neurocysticercosis: A randomised controlled trial
(2008-06) Kelvin, Elizabeth A.; Carpio, Arturo; Bagiella, Emilia; Leslie, Denise; León, Pedro; Howard, Andrews; Hauser, W. Allen; Lisanti, Noemí; Aguirre, R.; Serrano, M.; Pesántes, J.; Moncayo, J.; Roman, M.
AIM: The aim of this trial was to evaluate the effects of albendazole (ALB) on cyst disappearance, reduction of the number of cysts and seizure recurrence. METHODS: 178 patients with new onset symptoms due to active or transitional neurocysticercosis were randomly assigned to receive either 800 mg of ALB daily or placebo for 8 days. All patients also received prednisone. Imaging studies were done at baseline and at months 1, 6 and 12 of follow-up. RESULTS: Active cysts were identified in 59 of 88 people randomised to ALB and 57 of the 90 in the placebo arm. By 1 month, 31% were free of active cysts in the treatment group compared with 7% in the placebo group (p = 0.001). In addition, the ALB group had a greater reduction in the number of active cysts compared with the placebo group (p = 0.001). After 1 month following treatment there was no additional gain by treatment group in the disappearance or reduction in the number of active cysts. ALB treatment had little effect on cysts in the transitional or calcification stage. We found no difference between the ALB and placebo groups in symptoms during treatment or in seizure recurrence during the 12 months after treatment. CONCLUSION: Albendazole plus symptomatic treatment leads to the disappearance of active cysts in 31% of patients compared with 7% of those with symptomatic treatment alone. This treatment effect occurs within the first 30 days after treatment.
Epilepsy in the developing world
(2009-07-09) Carpio, Arturo; Hauser, W. Allen
Developing countries (DCs) and developed countries have geographic, economic, and social differences. The prevalence and incidence of epilepsy are higher in DCs than in developed countries. However, within DCs, given the high incidence of epilepsy, the prevalence is relatively low, which may be due to high mortality for people with epilepsy (PWE). Neurocysticercosis is one of the main causes of symptomatic epilepsy in many DCs. Prognosis in DCs seems similar to that in developed countries. Because phenobarbital and phenytoin are available and inexpensive, they are the drugs most often used in DCs. The cost of newer antiepileptic drugs and the limited availability of resources for epilepsy care in DCs mean that care for PWE in DCs is marginalized and that many people receive no pharmacologic treatment. The most cost-effective way to decrease the treatment gap in DCs would be to deliver the epilepsy services through primary health care.
Investigation of familial aggregation of seizures in neurocysticercosis patients
(2009-03) Kelvin, Elizabeth A.; Carpio, Arturo; Bagiella, Emilia; Leslie, Denise; León, Pedro; Howard, Andrews; Hauser, W. Allen; Hesdorffer, Dale C.
Regional differences in the clinical manifestations of human neurocysticercosis (NCC) may indicate a role of host genetics. We examined whether there is familial aggregation of seizures in first-degree relatives of NCC patients with seizure versus NCC patients without seizure as presenting symptom in a group of patients in Ecuador. The results of our analyses were null, and there was no trend toward familial aggregation of seizures in NCC patients.
Is the course of neurocysticercosis modified by treatment with antihelminthic agents?
(1997-01-13) Carpio, Arturo; Santillán, Franklin; León, Pedro; Flores, Carlos; Hauser, W. Allen
Del Brutto should not be surprised by the results of our clinical trial of treatment of neurocysticercosis (NC).1 A series of articles were published in JAMA to "help physicians translate the results of medical research into clinical practice."2 In one of them, the authors state that "to the surprise of many and the indignation of a few," well-conducted randomized clinical trials have contradicted the results of less rigorous studies supporting therapies previously considered "standard" practice.3 To address comments related to the sequence of our studies, we must provide a brief background for the current report. In January 1984, we received support from the Consejo Nacional de Universidades y Escuelas Politécnicas del Ecuador (CONUEP), the institution responsible for scientific research in our country, for a project titled "Clinical Aspects of Neurocysticercosis in Ecuador." In this project, we performed a retrospective review of cases treated for NC between 1984
Letter to the editor
(1998-12-11) Carpio, Arturo; Del Brutto, Oscar H.
Mortality of Epilepsy in Developing Countries
(2005-12-14) Carpio, Arturo; Bharuch, N. E.; Jallon, P.; Beghi, Ettore; Campostrini, R.; Zorzetto, S.; Mounkoro, P. P.
During the last two decades, there has been a renewed interest in studying epidemiology of epilepsy in developing countries. While there are data on prevalence of epilepsy from many developing countries, there is very little information on the mortality of epilepsy in these same populations. This is because incidence studies of epilepsy are difficult to perform, death certificates are unreliable and often unavailable, and the cause of death is difficult to determine. We report on several studies of mortality in epilepsy in developing countries: Ecuador; the Parsi community of Bombay; a semiurban community in Vasai, India; Mali; Martinique; and Africa. Overall, these studies in general illustrate excess mortality among people with epilepsy when compared with the general population.
Neurocysticercosis and epilepsy in developing countries
(2001) Pala, Deb K.; Carpio, Arturo; Sander, Josemir W. A. S.
Objective: To estimate the number of sudden unexpected epilepsy deaths occurring annually in England and Wales in those 16–50 years of age. Methods: All 1997 death entries mentioning epilepsy as a cause of death in those 16–50 years were examined and classified as sudden unexpected death in epilepsy (SUDEP), other epilepsy related deaths, or non-epilepsy deaths. Results: 612 death entries were obtained with postmortem examination having been performed in 498 cases. Forty four deaths were certified as being attributable to SUDEP and a further 292 deaths were considered to be probable SUDEP cases. Conclusion: It is estimated that between 350 and 400 cases of SUDEP occurred in England and Wales in 1997 in those 16–50 years. SUDEP is the commonest category of epilepsy related death and accurate certification of such deaths is vital for the monitoring of trends in mortality.
Neurocysticercosis: an update
(2002-12) Carpio, Arturo
Taeniosis and cysticercosis, diseases caused by the parasitic tapeworm Taenia solium, are distributed worldwide where pigs are eaten and sanitation is poor, and also in the more developed countries as a result of increasing migration. Neurocysticercosis is the commonest parasitic disease of the human nervous system. Immunological assays detect positivity for human cysticercosis in 8–12% of people in some endemic regions, which indicates the presence of antibodies against the parasite but not necessarily active or central-nervous-system infection. The only reliable tool for diagnosis of neurocysticercosis is imaging by CT or MRI. The presence of viable cysts with a mural nodule, associated with degenerative cysts and calcifications, is typical. Classification of neurocysticercosis into active, transitional, and inactive forms gives a good clinical-imaging correlation and facilitates medical and surgical treatment. The main clinical manifestations of neurocysticercosis are seizures, headache, and focal neurological deficits, and it can have such sequelae as epilepsy, hydrocephalus, and dementia. Treatment should be individually fitted for each patient, with antiepileptic drugs, analgesics, corticosteroids, or a combination of these. Anthelmintic drugs (praziquantel and albendazole) are used routinely, but so far no controlled clinical trial has established specific indications or definitive doses of treatment. Parenchymal forms of neurocysticercosis have a good prognosis in terms of clinical remission. The most effective approach to taeniosis and cysticercosis is prevention, which should be a primary public-health focus for less developed countries
Prognosis for seizure recurrence in patients with newly diagnosed neurocysticercosis
(2002-12-10) Carpio, Arturo; Hauser, W. Allen
bjective: To determine the risk of seizure recurrence after a first seizure due to neurocysticercosis (NC) and to evaluate risk factors for seizure recurrence, including the influence of antihelminthic treatment. Methods: The authors prospectively followed 77 patients with a first seizure and active or transitional NC for >7 years (median 24 months). Results: Thirty-one patients (40.3%) experienced seizure recurrence. Kaplan–Meier estimated recurrence was 22% at 6 months, 32% at 12 months, 39% at 24 months, and 49% at 48 and 84 months. Treatment with an antihelminthic (albendazole) did not influence recurrence. On multivariable analysis, none of the following predicted recurrence: sex, presenting seizure type, classification of NC, localization of cysts, Todd paralysis, neurologic deficits at presentation, EEG abnormalities. Only change in CT predicted recurrence: 22% in patients in whom cysts disappeared and 56% in patients with persistent cysts (p < 0.05). In this latter group, recurrence was associated with persistence of an active lesion. Of those with two seizures, estimated risk of a third seizure was 68% by 6 years after the second seizure. Conclusions: Seizure recurrence is high after a first acute symptomatic seizure due to NC, but this seems related to persistence of active brain lesions. Recurrence risk is low and in keeping with seizure risk following other brain insults leading to a static encephalopathy in those in whom the NC lesion clears. Patients with NC should receive antiseizure medications until the acute lesion clears on CT. There is no correlation between treatment with antihelminthic agents and seizure recurrence
Recommendation for a definition of acute symptomatic seizure
(2010-04) Beghi, Ettore; Carpio, Arturo; Forsgren, Lars; Hesdorffer, Dale C.; Malmgren, Kristina; Sander, Josemir W. A. S.; Tomson, Torbjörn; Hauser, W. Allen
PURPOSE: To consider the definition of acute symptomatic seizures for epidemiological studies, and to refine the criteria used to distinguish these seizures from unprovoked seizures for specific etiologies. METHODS: Systematic review of the literature and of epidemiologic studies. RESULTS: An acute symptomatic seizure is defined as a clinical seizure occurring at the time of a systemic insult or in close temporal association with a documented brain insult. Suggestions are made to define acute symptomatic seizures as those events occurring within 1 week of stroke, traumatic brain injury, anoxic encephalopathy, or intracranial surgery; at first identification of subdural hematoma; at the presence of an active central nervous system (CNS) infection; or during an active phase of multiple sclerosis or other autoimmune diseases. In addition, a diagnosis of acute symptomatic seizure should be made in the presence of severe metabolic derangements (documented within 24 h by specific biochemical or hematologic abnormalities), drug or alcohol intoxication and withdrawal, or exposure to well-defined epileptogenic drugs. DISCUSSION: Acute symptomatic seizures must be distinguished from unprovoked seizures and separately categorized for epidemiologic purposes. These recommendations are based upon the best available data at the time of this report. Systematic studies should be undertaken to better define the associations in question, with special reference to metabolic and toxic insults, for which the time window for the occurrence of an acute symptomatic seizure and the absolute values for toxic and metabolic dysfunction still require a clear identification.
Routine drug and food interactions during antihelminthic treatment of neurocysticercosis: a reason for the variable efficacy of albendazole and praziquantel?
(2014-04) Romo, Matthew L.; Carpio, Arturo; Kelvin, Elizabeth A.
Neurocysticercosis (NC) or infection of the central nervous system with Taenia solium larvae is a leading cause of preventable seizures and epilepsy in endemic regions across the globe. Albendazole and praziquantel are commonly used antihelminthic agents to treat NC; however, viable cysts persist in the majority of patients, putting them at risk for future seizures and other neurological complications. Because of their pharmacokinetic profiles, albendazole and praziquantel have the potential to interact with many different drugs. During antihelminthic treatment, antiepileptic drugs and corticosteroids are commonly co-administered to manage seizures and cerebral edema; however, the most commonly used agents from these drug classes are known to significantly alter plasma concentrations of albendazole and praziquantel. The overarching issue with drug interactions during the treatment of NC is whether or not they have clinical relevance, as the plasma concentrations of albendazole and praziquantel have not been directly linked with eradication of viable cysts. Future studies should attempt to evaluate the validity of a causal relationship between antihelminthic plasma concentrations and outcomes so that drug interactions can be better understood and managed and so that treatment can be optimized.
Seizure in people with newly diagnosed active or transitional neurocysticercosis
(2011-03) Kelvin, Elizabeth A.; Carpio, Arturo; Bagiella, Emilia; Leslie, Denise; León, Pedro; Howard, Andrews; Hauser, W. Allen
Purpose: The aim of this study is to describe seizure as a presenting symptom in individuals with recently diagnosed neurocysticercosis (NCC). Methods: Using logistic regression, we examined the probability of having seizures as a presenting symptom among those with active or transitional NCC by host age and gender, and by number of cysts, location of the cysts in the brain, and phase of evolution of the encysted parasite. Results: We found that the odds of having seizures as presenting symptom for those in the youngest age group (3–24 years old) were 12.9 times that of the oldest participants (age 55–82 years) (p = 0.006). People with cysts in parenchymal locations had a significantly higher odds of seizures compared to those with all their cysts elsewhere (ventricles or subarachnoid) (OR = 6.2, p = 0.028); and the number of cysts was significantly associated with having seizures (OR = 1.1, p = 0.026). Host gender and cyst phase were not significantly associated with having seizures after adjusting for confounders and covariates. Conclusion: Children, those with cysts in parenchymal locations, and those with a higher number of cysts appear to be more likely to experience seizure when they have NCC cysts in the active or transitional stage.
Should calcified neurocysticercosis lesions be surgically removed?
(2014-02) Carpio, Arturo; Romo, Matthew L.
Taenia solium seropositivity in patients with active epilepsy
(2014-11) Romo, Matthew L.; Carpio, Arturo