NT, a 10-year-old girl, was seen in June 1957 suffering from headache of 7-month duration accompanied by progressive right-sided weakness of 6.5-month duration. On examination, she had tremors in the right hand and crackpot resonance. Plain skull x-ray revealed separation of sutures. Ventriculography was carried out, and the cyst was inadvertently punctured. The films revealed a cyst in the left parietal region (Fig. 17.2). A small craniotomy was performed, and, through the intact dura, the cyst was twice filled with 1 % formalin which was left in the cyst cavity for 5 min each time and then irrigated profusely with normal saline solutions. The dura was then opened and the cyst removed through a small cortical incision. A severe postoperative reaction occurred, accompanied by fever, subsiding on the 13th postoperative day. A month after surgery, the patient was well. No further follow-up was possible.

RM, an 11-year-old boy, was seen for the first time on January 19, 1980, for headache of 3-year duration diagnosed as migraine. A month prior to his consultation, the headache became very severe, and a plain skull x-ray revealed separation of the sutures, with a decreased uptake in the left frontal area on isotope scanning. On examination there was no papilledema, but a crackpot resonance was obtained. Because of the above and his relatively good general condition, he was suspected of harboring a cerebral hydatid cyst. His family preferred him to be operated in France. His brother, a medical student who was accompanying him, was told that this was most probably a hydatid cyst and was asked to warn his surgeon in Paris not to puncture the lesion and that he, the surgeon, should be aware of that diagnosis and should do his best to deliver the cyst intact. The surgeon did not heed the advice and thought he was dealing with a cystic astrocytoma. When the dura was opened, the brain bulged, and the surgeon introduced a needle in the brain to reduce the pressure. Clear fluid spurted out and the brain relaxed; the surgeon carried out an incision in the cortex and pulled the chitinous membrane, closed the wound, and discharged the child in perfect health. This child was well until 8 months later, August 1980, when he suffered from headaches. CT scan of the brain became available in Lebanon; it was performed and revealed a cyst in the operative field. He was advised surgery but was lost to follow-up until March 28, 1981, at which time he suffered from severe weakness in the upper extremities with bilateral Babinski sign, absent knee and ankle jerks, saddle anesthesia, and urinary retention. He was being treated for a Guillain-Barré syndrome. A cisternal myelogram (CT myelography was not yet in use) revealed a complete block at C6. Following that test, the patient became completely paralyzed from C6 down with a flicker of movement in the left lower extremity. An emergency lumbar myelogram was performed with a puncture at L5–S1 to delineate the lower extent of the lesion. It revealed multiple subarachnoid space-occupying lesions extending from S2 to L2. The contrast medium did not flow beyond L2. The findings were suggestive of multiple subdural spinal hydatid cysts. An emergency surgery was performed on March 31, 1981, first on the cervical spine, from where a 3 cm cyst was removed intact from the spinal subarachnoid space at the C6 level. Then a laminectomy from S2 to L2 was performed, and four cysts were removed, two intact and two ruptured; the latter two had been punctured at the time of myelography (the needle punctures were clearly seen). The cervical and lumbar areas were thoroughly irrigated with 0.1 % cetrimide solution and the wounds closed. The patient gradually recovered his movements and sensations in the upper and lower extremities. Two weeks later, a myelogram, using the residual dye left in the spinal canal, revealed the presence of more cysts in the dorsal region (Fig. 17.3a). On April 16, a third laminectomy, joining the previous cervical and lumbar laminectomies, was performed, and the remaining six subarachnoid cysts were delivered intact from the dorsal region (Fig. 17.3b). The patient made a perfect recovery except for some urgency on urination and was discharged on May 1, 1981. On November 30, 1981, about 7 months after his discharge from hospital, he was readmitted because of bouts of headache and vomiting of 3-week duration. About 23 months from the initial surgery, on December 1, 1981, the left frontal craniotomy was reopened, and two recurrent frontal cysts were removed intact from the bed of the original cyst (Fig. 17.3c, d). Since then he has done well.