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UntitledCerebral hydatid cyst: Successfully managed
Youssef Fares1,2, Mohamed El-Zaatari2, Georges Haddad3, Ali Kanj2
Abstract: We presented 9 cerebral hydatid cyst cases, 2 children and 7 adults, admitted to Hammoud Hospital,
University Medical Centre over 10 years. The clinical manifestations can extend over several months, showing
headache, vomiting, visual and motor symptoms, and convulsions with mental changes. Adults showed more rapidly
developing symptoms than children. Diagnosis was based on brain CT or MRI. All cases were successfully treated
surgically with full delivery of an unruptured cyst.
Key words: Brain hydatid, cerebral hydatid cyst, new surgical and technical approach. (p9-11)
Hydatid cyst (echinococcosis) is an endemic disease that
Hydatid cysts of the brain, single or multiple, are unique, affects a wide sector of the world population. Published usually supratentorial and located within the distribution data reveals that this disease is a cause in increasing human drive of the middle cerebral artery (Fig. 1). The cysts can
morbidity.6,20 It was recognized in old times, Hippocrates grow to a large size, usually measuring to an average of 5 - and Galen made references to the hepatic forms of such 6 cm in diameter. Cysts as large as 15 cm in diameter were parasitic infestation. The cestode (tapeworm) of the dog "Echinococcus granulosus" is the parasite causing the dis-ease. The disease is widely spread around the world. Humans are accidental intermediate hosts and catch the disease by ingesting the hexacanth ova in contaminated vegetables or by direct contact after patting infested dogs or farm animals. The ova hatches in the intestine and the larvae reach the liver through the portal system. The most common areas of localizations are hepatic 66% and pulmonary 10%, repre-senting 76% of the cases. The nervous system is affected in 3 - 7% of patients, other sites affected include abdominal in 8%, kidneys in 7% and bones in 2%. Figure 1 - Revealing well-defined rounded cystic lesion of the
right cerebral hemisphere compatible with large hydatid cyst.
Materials and methods
We have performed a prospective study regarding 9 cases of hydatid cyst in the brain that were treated surgically over a period of 10 years (1993 - 2004). The patients included: 2 2Neurosurgery, Laboratory & Radiology Services children (7 and 11 years respectively) and 7 adults (5 males Hammoud Hospital University Medical Centre and 2 females), ages between 21 and 51-years-old, for a mean age of 47 years (Table 1).
Lebanon 3Department of Neurosurgery American University of Beirut Table 1 - Distribution of cerebral hydatid cyst by age.
Age in years
Female 2 1
Dr. Youssef Fares Neurosurgery, Laboratory & Radiology Services No. of cases 2
Hammoud Hospital University Medical Centre Saida Lebanon Elapsed time between the beginning of symptoms and the seeking of medical help range from 3 months to one year. VOLUME 15, NO. 2, OCTOBER 2011
CEREBRAL HYDATID CYST: SUCCESSFULLY MANAGED • Fares, et al
Patients were coming from rural surroundings, their occu- the cyst is directed towards the ground. The anaesthetist is pations were related to cattle and agriculture. then asked to provide a Valsalva manoeuvre thus increasing the ICP, which will help in expulsing the cyst. The cyst All the patients underwent a CT scan, and 4 of them under- weight and the sterile saline solution force help in extracting went additional MRI of the brain. The cysts measured from the cyst and ejecting it intact into a kidney basin. Some minimal pressure on the adjacent cortex may be useful. The cyst should be gently delivered over cetrimide wet gauze Blood tests revealed increased sedimentation rate in 80% stretched from the brain into the kidney basin to avoid con- and leukocytosis in 35% of the cases. Clinical manifesta- tact with any sharp surface edges like bone edges and tions were mainly related to increased ICP and local brain compression by the cyst (Table 2).
Table 2 - Clinical manifestation of cerebral hydatid cyst seen
in all patients.
Adults / %
Pyramid follow through of the dysfunction Figure 2 - Intraoperative images reveal the hydatid cyst during
Adults showed rapid progression of the disease in 85% of the cases: visual disturbances in 86%, papillaoedema in 43%, and mental disturbances in 71%. Motor or sensory deficits were present in 30% and convulsions in 30%. The All 9 patients underwent surgical removal of the brain cyst localization was shown in Table 3: right parieto-occipital in
with 2 mortalities; an 8-year-old girl who died suddenly 3 3 cases, left fronto-parietal in 3 cases, left parietal in 2 cases weeks after discharge from the hospital. An urgent CT scan and right parieto-temporal occipital in one case. demonstrated a major para-encephalic cyst displayed within the operated zone causing herniation of the brain. We do Table 3 - Localization of the brain hydatid cyst.
consider that the hypertonic saline washing, left within the Localization
No. of cases Supratentorial
cavity after delivery of the cyst, lead to an increase of pres- sure in the cavity after removal the cyst. The second patient was an adult male who presented with evolution 3 years following surgery; he was showing many affected organs with multiple cysts in his lungs, liver and metaperitonium of the abdomen.
Two patients were re-operated due to recurrence of hydatid All patients underwent a craniotomy making sure to mini- cyst. The remaining 5 patients had a 100% cure after sur- mize vibration to prevent cyst rupture as the craniotomy incision was made at least 2 cm larger than the actual cyst size. The dura was opened with care and the incision was Discussion
made outside the boarders of the cyst to prevent cutting into Brain localization of hydatid cyst represent between 1 - the cyst wall. Care should be taken, not to use anticoagula- 5.3% of hydatid cysts: 1% according to Draout(3), 2% ac- tion devices like bipolar system, as the heat generated might cording to Krajewski(11), and 5.3% according to Mahfoud.14 cause rupture of the cyst. As soon as the cyst was exposed Frontal and parietal localizations are the most frequent ones. (Fig. 2), the brain is softly massaged, using from time to
Children usually present with single cyst in the brain(1,4), time saline to separate the cyst edge from the underlying and have long-term tolerance to the symptoms and develop- brain surface. At a later stage, the head is rotated in a way so ment of a large cyst.10,12,13 Multiple cysts are very rare and PAN ARAB JOURNAL OF NEUROSURGERY
CEREBRAL HYDATID CYST: SUCCESSFULLY MANAGED • Fares, et al
may result either from spontaneous, traumatic or surgical currence usually sets in giving rise to multiple cysts.16 rupture.13,17,18 They may also occur after a showering of emboli from an extracranial cyst rupture.5,13,19 The clinical References
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tumour, brain abscess, dermoid and epidermoid cyst, neuro- 12. Le Hoang P, Renault F, Lombardo JC, Roy C, Harry JP, Fontaine cysticercosis and glioma. The treatment of the hydatid cyst M: A propos d'une cause rare de syndrome de Foster- is easy, especially if it is a unique cyst. The rupture risk dur- Kennedy: l'hydatidose cérébrale. Bull Soc Opht Fr 1994, 84
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is achieved but in case of accidental rupture of the cyst re- VOLUME 15, NO. 2, OCTOBER 2011
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