Multiseptated cerebral hydatid cysts with preoperative diagnostic uncertainty and suspected renal and splenic involvement: a case report

Cerebral cystic echinococcosis is uncommon and is usually reported in children or young adults as a solitary intracranial cyst. Atypical morphology, multiplicity, and perilesional edema may obscure preoperative recognition. Because cyst rupture can lead to dissemination, recurrence, and severe inflammatory or anaphylactic complications, intraoperative recognition has important surgical implications. A 66-year-old man presented with a 2-week history of progressive left hemiparesis. Contrast-enhanced 1.5-T brain magnetic resonance imaging demonstrated two closely adjacent but distinct multiseptated right parietal cystic lesions measuring 70 × 35 mm and 57 × 40 mm, with vasogenic edema, mass effect, and 5 mm midline shift. The lesions did not enhance or restrict diffusion. Multivoxel magnetic resonance spectroscopy showed prominent lactate elevation without a tumor-type choline increase, but no specific diagnosis was established. During right parietal craniotomy, the macroscopic appearance and dissection characteristics raised suspicion of hydatid disease. Two distinct parent cysts with separate but closely apposed capsules were identified; each contained daughter cysts. Both cysts were removed intact using normal-saline Dowling hydrodissection supplemented by circumferential microsurgical dissection. Histopathology confirmed cerebral cystic echinococcosis. Postoperative staging identified asymptomatic splenic and right renal cystic lesions considered suspicious for additional hydatid involvement, although neither was pathologically confirmed. Albendazole was initiated postoperatively, and left-sided motor strength recovered to 5/5 at 1 month. Cerebral hydatid disease should remain in the differential diagnosis of atypical non-enhancing intracranial cystic lesions, even in older adults. When preoperative imaging is inconclusive, intraoperative recognition may permit rupture-avoiding excision. Systemic staging is important after diagnosis and may disclose clinically silent extracranial cystic lesions that require multidisciplinary assessment and cautious characterization.