PMC9163400_01
Initial non-contrast CT of the head demonstrating left temporal cyst.
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Initial non-contrast computed tomography (CT) scan (Figure 1) demonstrated a left sided temporal cyst. As part of the workup, abdominal x-ray was obtained which showed evidence of radio-opaque material (Supplementary Figure 1), which prompted workup for heavy metal poisoning.
The patient exhibited anisocoria and severe headache following hospital admission. Follow-up CT scan demonstrated profound cerebral edema and downward tonsillar herniation. An EVD was successfully placed (left image).
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In addition, there were subtle FLAIR hyperintensities in the bilateral parietal and occipital lobes that thought to be secondary to leptomeningeal enhancement (Supplementary Figure 2). A second emergent CT scan of the head was obtained, demonstrating downward cerebral tonsillar herniation and global edema (Figure 2).
Intracranial pressure (ICP) was monitored continuously via the patient's ventriculostomy. British anti-Lewsite (BAL: dimercaprol) injection times likely corresponded to intermittent elevations in ICP. Optimal pain sedation with hydromorphone, midazolam, and lidocaine helped mitigate the severity of the spikes. A steady decline in the patient's lead levels corresponded to improvement in her cerebral edema and ICP. Lead concentration was 14 mcg/dl at 5 days post-EVD removal.
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A pain protocol of lidocaine 2% intramuscularly at the injection site prior to BAL administration followed by intravenous hydromorphone (2 mg) after injection reduced the severity of ICP spikes over time (Figure 3).
Non-contrast CT scan demonstrating improved cerebral edema on day of EVD removal.
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The EVD was then removed at 13 days post-insertion (Figure 4).