Delayed cerebral vasospasm and systemic inflammatory response syndrome following intraoperative rupture of cerebral hydatid cyst

Abstract

Dear Editor, Treatment for symptomatic cerebral hydatid cyst is usually surgical excision. Surgery for cerebral hydatid cyst remains tricky, as inadvertent rupture may cause dissemination and occasionally allergic shock [3]. We report an unusual complication of delayed cerebral vasospasm and systemic inflammatory response syndrome (SIRS) following intraoperative rupture of hydatid cyst. A twenty-two-year old male presented with bifrontal headache for 5 years that worsened over the last 4 months, along with vomiting and left brachio-facial weakness in the last 1 month. Radiology revealed multiloculated large cystic lesion in the right temporal lobe, with the cyst walls partly enhancing (Fig. 1a–d). The lesion was approached through middle temporal gyrus, and multiple white translucent cysts were encountered, adhered to the medial temporal lobe and tentorium. Though the cysts were excised completely, there was some spillage of fluid from the inadvertent rupture (due to adhesions) of the first cyst into the cisternal spaces. Thereafter, 10 % betadine-soaked gauze was put over the operative cavity for 30 min, followed by thorough saline lavage. The cyst fluid showed scolices of echinococcus granulosus with several protoscolices and hooklets. The immediate pos operative period was uneventful. Twenty-four hours later, the patient became drowsy and developed left grade 3/5 hemiparesis with low grade fever. Blood examination showed marked leucocytosis. CT scan of the head showed diffuse brain edema with no infarcts (Fig. 1e– g). In view of new focal neurological deficit after a day, vasospasm was suspected. Cerebral digital subtraction angiography (DSA) revealed diffuse vasospasm of bilateral vertebral, basilar posterior cerebral arteries and focal vasospasm of the right posterior communicating artery. Intraarterial nimodipine was infused in bilateral vertebral and internal carotid arteries that showed radiological improvement of vasospasm (Fig. 1i–l). However, there was no clinical improvement. Diagnostic lumbar puncture and cerebrospinal fluid (CSF) examination revealed cell count of 170/dl (55 % neutrophils) and normal sugar. CSF culture was sterile. His sensorium worsened over the next 2 days, alongwithworsening of hemiparesis to left hemiplegia. High grade fever had set in and leucocytosis persisted. Blood, urine and tracheal aspirate culture did not show any growth. Steroids were administered. On the fourth post-operative day, the patient became hemodynamically unstable. Haematological workup showed pancytopenia. He expired a day later. Repeat CT head showed no new findings (Fig. 1h). Unfortunately, an autopsy was not performed. Cerebral hydatidosis is often encountered in developing countries [3]. The intraparenchymal cysts are usually unilocular cysts and tend to occur in the middle cerebral artery territory. These are non-enhancing spherical cystic lesions without perilesional edema. With progressive neurological deficits and raised intracranial pressure (ICP), surgical excision remains the treatment of choice. A high index of suspicion is necessary as intraoperative cyst rupture is not desirable. The preoperative diagnosis, however, may be missed in case of multiple loculations and wall enhancement as in the index case. Besides, despite all attempts to avoid cyst Not presented at any conference.