|Year : 2014 | Volume
| Issue : 4 | Page : 263-266
Intracranial hydatid cysts-some rare presentations of cases
Ramanjulu Mala, ML Ananth, BN Nagaraju, C Venkateswara Rao
Department of Neurosurgery, Kurnool Medical College, Government General Hospital, Kurnool, Andhra Pradesh, India
|Date of Web Publication||10-Dec-2014|
Department of Neurosurgery, Kurnool Medical College, Government General Hospital, Kurnool - 518 002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
We are here with presenting four cases of intracranial hydatid cysts that are managed at Department of Neurosurgery, Government General Hospital Kurnool between 2010 and 2013. The mean age of presentation is 25 years. One patient had primary solitary cyst, second patient had primary unilateral multiple cysts, third patient had secondary (metastatic) bilateral multiple cysts and fourth had secondary multiple cysts presenting with unilateral proptosis. All patients were presented with signs of raised intracranial pressure. Radiological investigations included computed tomography and magnetic resonance imaging.
Keywords: Albendazole, hydatid cysts, multiple cysts, proptosis
|How to cite this article:|
Mala R, Ananth M L, Nagaraju B N, Rao C V. Intracranial hydatid cysts-some rare presentations of cases. J NTR Univ Health Sci 2014;3:263-6
| Introduction|| |
Hydatid disease is a parasitic disease that affects both humans and other mammals, such as sheep, dogs, rodents and horses. Most common form found in humans is caused by larval stages of tape worm Echinococcosis granulosus. The definitive hosts are carnivores such as dogs, while intermediate hosts are sheep and cattle. Humans are accidental intermediate hosts, are usually the dead end for the parasitic cycle. The adult worm resides in the small intestine of a definitive host. The eggs are passed in feces of the definitive host. The egg is then ingested by the intermediate host. The egg hatches in the small intestine of the intermediate host and penetrate the small intestine and moves through the circulatory system into different organs commonly liver and lungs, where the larvae get entrapped and encysted and some pass through the capillary filter of liver and lungs and get into systemic circulation and reach the brain, bone and other organs. , Intracranial hydatid cysts are usually primary solitary, but may be primary multiple unilaterally or bilaterally or secondary multiple. 
| Case reports|| |
Here we report a case of an 18-year-old female patient who admitted with a history of head ache of 1 year duration with decreased vision and papilledema. Brain computed tomography (CT) showed a large well-defined cystic lesion in the left temporal region with no significant edema and with no enhancement [Figure 1].
|Figure 1: Computed tomography Image showing large single unilocular cystic lesion in left temporo parietal region of brain|
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A 40-year-old man admitted with head ache of 1 year duration, seizures and vomitings of 1 week. Magnetic resonance imaging (MRI) showed two well-defined cysts in right parieto-occipital region [Figure 2].
|Figure 2: Magnetic resonance imaging showing two cystic lesions in parieto occipital region of brain|
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A 40-year-old female admitted with a history of seizures and drowsiness. She had papilledema. Brain CT showed multiple well-defined cystic lesions in both hemispheres of brain [Figure 3]. Abdominal CT scan revealed associated hydatid cyst in spleen [Figure 4] and right internal iliac [Figure 5]. Echocardiography shows hydatid cyst in the heart.
|Figure 3: Computed tomography scan showing multiple cystic lesions in different locations of brain|
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|Figure 4: Computed tomography abdomen showing hydatid cysts in the spleen|
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|Figure 5: Angiogram showing blockage of right internal iliac artery due to hydatid cysts|
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A 25-year-male admitted with proptosis of right eye of 1 month duration and with a history of craniotomy 3 year back. MRI showed multiple extradural lesion in the right frontal, temporal and right orbital region are probably secondary multiple hydatid cysts as result of spillage at previous surgery resulting in recurrence [Figure 6].
|Figure 6: Magnetic resonance imaging showing right intra orbital and temporal (extra dural) hydatid cysts|
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| Discussion|| |
Intracranial hydatid cysts are rare, accounting for only 1-2% of all intracranial space occupying lesions.  Hydatid cyst of the orbit are rare, is responsible for nearly 1% of all orbital growths.  In India, the hydatid disease is more commonly seen in the Kurnool district of Andhra Pradesh, Madurai district of Tamil Nadu and in Punjab. ,,, The incidence in India is 0.2%. Cerebral hydatid cyst is more common in pediatric population.  Cerebral hydatid cysts are usually supra tentorial and often involve middle cerebral artery territory because of the embolic nature of the infestation.  The common location in parietal lobe has been reported by Gupta et al. and Abu-Eshy  in their series. Cerebral hydatid cysts commonly occur in children and young adults.
The human brain can be involved primarily through hematogenous route or by metastatic spread when a cyst ruptures in the heart or lung. The cysts may be single (primary) or multiple (secondary). ,,,, The primary solitary cysts are formed as a result of direct infestation of larvae in the brain without demonstrable involvement of other organs. In primary multiple cysts, each cyst has a separate pericyst with brood capsule, scolices and they originate from multiple larvae that affect brain after crossing the gastrointestinal tract, liver, lungs and right side of the heart without affecting them. Primary cysts are fertile as they contain scolices and brood capsule, hence the rupture of the primary cyst can result in recurrence. Multiple hydatid cysts usually results from cardiac embolus. Secondary multiple cysts results from spontaneous, traumatic or surgical rupture of the primary intracranial hydatid cyst and they lack brood capsule and scolices. , The secondary intracranial cysts are therefore infertile (acephaloceles) and the resultant risk of recurrence after their rupture is negligible. The growth rate of hydatid cysts of the brain is higher than in other organs, has been variably reported between 1.5 and 10 cm/year.  Multiple intracranial cysts are rare. Onal et al. ,,, found only three cases in their series.
Patients with intracranial hydatid cysts usually presents with focal neurological deficits and features of raised intracranial pressures. The diagnosis of hydatid cysts is based upon clinical suspicion particularly in endemic areas. The Casoni and Weinberg tests, indirect hemagglutination, eosinophilia and ELISA are used in diagnosing hydatid cysts, but as brain tissue evokes minimal response many results tend to be false negatives. ,
Radiologically the best diagnostic clue of a hydatid cyst is a single large thin walled, spherical non-enhancing cyst, perilesional edema is usually absent. The diagnostic feature hydatid cyst on MRI is low signal intensity of cyst wall on T2 weighted image. 
The differential diagnosis of hydatid cyst includes arachnoid cyst, epidermoid cyst, cerebral abscess, cystic neoplasm. The echocardiography remains the most reliable test in the diagnosis and location of cysts within the cardiovascular system.
The aim of surgery is to excise the cyst without rupture to prevent recurrence and anaphylactic reaction. Antihelminthic therapy is beneficial and indicated in patients with spillage.
| Conclusions|| |
High index of suspicion is required despite the availability of advanced neuro-imaging. It is the benign lesion and the removal of the cyst without rupture is the most important to avoid spillage and recurrence of secondary multiple cysts. We concluded that based on the etiology and imaging findings all these rare cases are differentiated.
| Acknowledgments|| |
I thank professor of neurosurgery Dr. W. Seetharam. M.Ch., Dr. Joji Reddy professor of radiology and Dr. Janaki professor of pathology for his suggestions and review of this paper and Dr. Ananth. M.Ch., Dr. B. Nagaraju. M.Ch., Dr. Venkateswara Rao for collecting the data for this paper and for preparing the manuscript.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]