A Very Rare Complication of Cerebral Hydatid Cyst Surgery: Cortical Collapse

Abstract

Hydatid diseases are still endemic pathologies in developing countries which generally needs surgical treatment. The main aim of the treatment is total cyst evacuation without rupture. Dowling technique is preferable for this aim. There are various complications of hydatid disease surgery which include cortical collapse which is very serious and can be mortal. Our case was a 6-year-old boy diagnosed with a solitary isointense cystic mass in the left parietal region. There was no surrounding edema. The cyst was completely evacuated with Dowling technique without rupture. In about 10 min after evacuation, hemispheric cortical collapse occurred, and the patient developed cardiac arrest. Although cortical collapse is a rare complication, it can cause perioperative mortality. Special care and efforts should be taken as not to form large defects after cyst evacuation to prevent cortical collapse and related mortality.

INTRODUCTION

Hydatid cyst disease is an endemic condition in developing countries. The intracranial form has an incidence of 1.2% and is usually detected under 16 years (% 75).[1] The lesion can be solitary or multiple in the cranium, and the surgery is still the preferable treatment which aims to evacuate the cyst without rupture. Cyst rupture has many complications such as anaphylaxis, recurrence, infections including meningitis, and brain abscess.[2] Other rare surgery-related complications include porencephalic cyst, subdural or epidural hematoma, seizure, hydrocephalus, transient neurological deficits, and cortical collapse.[3] Cortical collapse can cause perioperative or early postoperative mortality reported up to 7%.[4]

CASE REPORT

A 6-year-old boy attended to our outpatient clinic with severe headache with a history of 1 month. He had no complaints of seizure and no neurologic deficit was detected. Laboratory analysis revealed leukocytosis without eosinophilia. Magnetic resonance imaging (MRI) showed a solitary, spherical, homogenous, and isointense cystic mass lesion without surrounding edema in the left parietal region which caused midline shift [Figures 1, 2 and 3].

Figure 1.

Axial T1-weighted magnetic resonance imaging of cyst. The patient consent forms for use this image has been obtained

Figure 2.

Coronal T2-weighted magnetic resonance imaging of cyst. The patient consent forms for use this image has been obtained

Figure 3.

Sagittal T1-weighted magnetic resonance imaging of cyst. The patient consent forms for use this image has been obtained

The patient was underwent to surgery. Parietal craniotomy was performed with classic high-speed drill. Corticotomy was performed at cyst localization. A silicone drainage catheter was placed between brain tissue and the cyst wall. Isotonic saline was slowly pushed in through this catheter to evacuate the whole cyst out (Dowling Technique). The cyst was completely evacuated without rupture [Figure 4], but a huge cavity occurred instead [Figure 5]. Approximately 10 min later after the evacuation, during hemostasis, hemispheric collapse occurred and the patient developed cardiac arrest. The collapse tried to be filled with saline infusion, but the patient could not be saved despite all resuscitation efforts. The patient considered to be exitus and the operation was terminated.

Figure 4.

The evacuated cyst. The patient consent forms for use this image has been obtained

Figure 5.

The huge cavity that formed after the cyst evacuation. The patient consent forms for use this image has been obtained

DISCUSSION

HC diseases are still endemic conditions in livestock farming regions such as South America, Middle East, and the Mediterranean. It is caused by larval stage of Echinococcus granulosus. The intermediate hosts of the parasite are sheeps, goats, and cattles, whereas the definite hosts are dogs and foxes. Children are usually presented with a solitary cyst in the brain and have long-term tolerance to the symptoms up to critical size.

Diagnosis of HD is established by neuroimaging. Computed tomography scan usually figure them as a well-bordered hypodense nonenhancing cystic lesion without surrounding edema. MRI usually scans them as hypointense mass with a hypointense halo around T2-weighted images. The differential diagnosis includes arachnoid cyst, porencephalic cyst, neurocysticercosis, and gliomas.[5]

Treatment of cerebral HC is surgical. The primary goal is total evacuation without rupture. Dowling technique provides to spare the cyst wall from brain tissue by hydrostatic pressure.[6] This technique enables evacuation without cyst rupture and reduces complication rate which is crucial to avoid conditions such as anaphylactic reaction, meningitis, and formation of multiple cysts.[7]

The most common complication is preoperative cyst rupture which can lead to widespread dissemination followed by severe inflammatory-anaphylactic reaction. Another perioperative serious mortal complication is cortical collapse which is reported to have low incidence. Seizure, subdural effusion, porencephalic cyst, hemorrhage, pneumocephalus, hydrocephalus, stroke, eosinophilic meningitis, and transient neurological deficits are other reported as other common postoperative complications while epilepsy, paresis, subdural effusion, ventricular dilatation, and recurrence have been reported to be low.[8]

The defect cavity formed after removal of large cysts may lead to mortal consequences such as cortical collapse, cardiopulmonary arrest, cerebral edema, hyperpyrexia, or subdural collection.[9] During perioperative and early postoperative period, the mortality rate of cortical collapse has been reported as high as 7%.[4] Pressed and displaced brain parenchyma may not replace to its original position and that can cause cardiopulmonary arrest.[10]

CONCLUSION

Although cortical collapse and related mortality have been reported low, it is a serious complication. Special care and efforts for a new surgical technique should be taken as not to form large defects which will prevent cortical collapse and related mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.