PMC9662852_01
Pre- and postoperative computed tomography images.
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(a) Preoperative image showing dilation of the subdural space due to cerebral atrophy. (b, c) Images immediately after operation. Air retention in the skull, but not intracranial hemorrhage, was observed. The lead was inserted at the target site.
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Head computed tomography (CT)/magnetic resonance imaging (MRI) showed dilation of the frontal subdural space due to marked brain atrophy (Fig. 1a). Postoperative CT showed that air was present in the skull due to the outflow of CSF, and no intracranial hemorrhage was observed (Fig. 1b, c).
Chronological time course of the present case.
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The horizontal axis in each row indicates the number of days since the surgery.
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Postoperative clinical time course was summarized in Fig. 2.
Radiographical findings shown in chronological order.
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Images were obtained on days (a) 7, (b) 14, (c, d) 16, (e) 28, (f) 33, (g) 42, (h) 49, (i) 71, (j) 78, (k) 89, and (l) 97.
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(a-h, l): Computed tomography.
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(i-k) Fluid-attenuated inversion recovery magnetic resonance imaging.
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(a) Edema was not seen in the images up to 7 days postoperatively, (b) but suddenly appeared 14 days after the operation. (c-d) Edema peaked on day 16 and extended to the tip of the lead. (e) After administration of steroids, the edema was reduced on the right side, but appeared on the left side. (f) The edema was enlarged predominantly on the left side. (g) After lumbar drainage, edema almost disappeared on both sides. (h) Edema reappeared on the left side on day 49. (i-k) Cysts formed around the left lead. (l) Eventually, both the cyst and edema disappeared.
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Head CT performed on the same day showed no brain edema (Fig. 3a). On the 13th day, the site of implantation in the left anterior chest suddenly became swollen, and CT on the 14th day showed marked cerebral edema around the right lead (Fig. 3b). Oral dexamethasone (9.9 mg/day) was administered, but on the 16th day, the edema around the right lead increased (Fig. 3c, d). On the 28th day, the edema around the right lead decreased; however, edema appeared around the left lead (Fig. 3e). A left anterior chest skin incision was made on the 33rd day (Fig. 3f and 4a, b), and serous fluid outflowed. The edema had nearly disappeared by the 42nd day (Fig. 3g). However, a CT scan on day 49 showed recurrence of edema around the left lead (Fig. 3h). After 71 days, MRI showed cyst formation around the left lead (Fig. 3i). The patient showed no response to steroid treatment as the edema persisted and the cysts increased in size (Fig. 3j). On the 89th day, the edema had decreased and the cyst disappeared; the patient was discharged from the hospital (Fig. 3k). On CT, the edema had disappeared completely by day 97 (Fig. 3l) and no recurrence was seen on CT after 4 months.
Cerebrospinal fluid leakage to the chest subcutaneous pocket.
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(a) Photograph before left chest resection performed at 33 days post-surgery. Cerebrospinal fluid accumulated under the skin of the chest, which is swollen. (b) Fluid collection was observed around the implantable pulse generator on computed tomography.
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A left anterior chest skin incision was made on the 33rd day (Fig. 3f and 4a, b), and serous fluid outflowed.