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Neurology India, Vol. 51, No. 2, April-June, 2003, pp. 295 Letter to Editor Surgery for multiple intracranial hydatid cysts B. V. Joseph, R. P. Haran, M. J. Chandy Accepted on 01.08.2001. Code Number: ni03105 Sir, Multiple intracranial hydatid cysts are rare and seen in about 10-15% of intracranial hydatid cysts.1 The treatment of intracranial hydatid cysts is essentially surgical, especially in patients with raised ICP or deficits.1,2 Intraoperative ultrasound (US) guidance is a useful adjuvant for surgery of such cystic intracranial lesions.3 A 53-year-old male presented with right-sided headache, vomiting and left hemiparesis for the past 2 months. He had left homonymous hemianopia, bilateral papilloedema, left upper motor neuron facial paresis, and left spastic hemiparesis. CT scan showed multiple right parietooccipital well-defined non-contrast enhancing hypodense cystic lesions (Figure 1). Mass effect on the ventricle and midline shift was observed. A right parieto-occipital craniotomy and total excision of 4 cysts was done. Following corticectomy, a cyst on the surface was removed by a combination of the Valsalva maneuver and water dissection technique. Another cyst beneath this was delivered through the same corticectomy in a similar manner. An anteriorly placed smaller cyst was delivered into the cavity created by the removal of the 2 cysts, but did not deliver itself out in spite of repeated attempts of a combination of the Valsalva maneuver and water dissection technique. Therefore the cyst contents were aspirated using a 26-gauge needle and the cyst wall was removed completely, after placing strips soaked in 1% cetrimide around it. The cavity was irrigated with the same solution. The fourth cyst, which was deeply situated inadvertently ruptured during removal _ the contents were immediately sucked out and the cyst wall was removed totally. No further cysts were seen. Postoperatively the patient was placed on Albendazole (400 mg twice daily). There was gradual improvement in his symptoms over a period of 4 days. A postoperative CT brain (Figure 2) showed that the anterior cyst had moved slightly posteriorly. In addition, 2 other cysts were seen. A right parietooccipital craniotomy was performed on the 5th postoperative day. There were no findings on the brain surface to locate the cysts. With the help of ultrasound, 4 cysts were identified. One of the cysts was seen bulging into the anterior wall of the cavity created at the first surgery, and was removed through the same corticectomy. A new corticectomy near the antero-inferior margin of the craniotomy was made to remove another cyst. Two other cysts were identified with the use of ultrasound between the 2 cavities created and were removed through the first corticectomy. Echocardiography, ultrasound abdomen and chest X-ray showed no evidence of extracranial hydatid cysts. Histopathology confirmed the presence of hydatid cysts, with germinal epithelium. At discharge the left-sided hemiparesis had improved, and he continued to have left homonymous hemianopia. CT scan done showed no residual cysts (Figure 3). Multiple intracranial hydatid cysts (MIHC) are rare and usually secondary, i.e. they are infertile and lack a brood capsule. Staged removal of MIHC has been reported when cysts are present in 2 different regions.4 Peroperatively, during the second surgery, a cyst was seen bulging into the anterior wall of the previously created cavity. It is interesting to note that this cyst had not bulged into the anterior wall during the first surgery. Following removal of the superficial cysts, it is likely that with associated brain shifts, the deeper cysts moved towards the cavity created. Ultrasound investigation during surgery was found to be helpful in locating the cysts. The main factor governing prognosis is the intact removal of the complete cyst, which is a curative procedure.4 In multiple hydatid cysts, removal of deeper cysts intact can be difficult. We feel that a technique not described earlier may be useful. An opened out gauze piece or a large strip soaked with 1% cetrimide or any other sterilizing agent, can be placed within the cavity created by the removal of the superficial cysts. The deeper cyst can be delivered into the cavity lined by the gauze piece/strip with the water dissection technique. The gauze piece/strip can then be removed with the intact cyst within it like a basket. REFERENCES 1. Ugur HC, Attar A, Bagdatoglu C, Erdogan A, Egemen N. Secondary multiple intracranial hydatid cysts caused by intracerebral embolism of cardiac echinococcosis. Acta Neurochir (Wien) 1998;140:833-4. Copyright 2003 - Neurology India. Also available online at http://www.neurologyindia.com The following images related to this document are available:Photo images[ni03105f1.jpg] [ni03105f2.jpg] [ni03105f3.jpg] |
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