Mrs. Rangmala, a 52-year-old housewife, presented with 11 months of right-sided weakness and headache, as well as recent difficulty speaking and urinary incontinence. MRI revealed a left frontoparietal arachnoid cyst. The surgical plan is a left fronto-temporal craniotomy and marsupialization of the cyst to relieve pressure and symptoms. Risks include bleeding, neurological injury, seizures, CSF leakage, and infection.

1. Preoperative case presentation
Dr. Md. Toufiq Hasan
Resident, Phase-A(R-9)
Department Of Neurosurgery
Dhaka Medical College Hospital
On behalf of NSU-Pink Unit

2. Particulars of the patient
 Name : Mrs Rangmala
 Age : 52 years
 Sex : Female
 Occupation : Housewife
 Marital status : Married
 Address : Zazira, Shariatpur
 Registration no : 71182/242
 Ward : 204
 Bed No : 47 (Non paying)
 DOA : 17/08/2023

3. Chief Complaints
 Weakness on the right side of the body for 11 months
 Headache for same duration.
 Difficulty in speech for 7 days.
 Continuous dribbling of urine for 7 days

4. History of present illness
According to the statement of the patient and her sons, she was reasonably well 11
months back. Then, she developed weakness on the right side of the body which was
painless, progressive, initially at right upper limb and then progressed to right lower
limb, could walk freely with hemiplegic gait pattern but from last10 days back, she
experienced a accidental fall and from then she can’t walk and her weakness is
increasing.

5. History of present illness (Cont.)
She also complained occasional headache for same duration which was
insidious in onset, mild in intensity, dull aching in nature, intermittent in
course, occurring anytime of the day, localized over vertex, no
aggravating factor and relieved by rest without taking any medication
and is not associated with vomiting or any other visual disturbances.

6. History of present illness (Cont.)
She also gave history of difficulty in speech from 7 days back , initially
she can’t talk but now difficulty in talking with confusion and poor
comprehension.
She also gave history of bladder dysfunction in form of continuous
dribbling of urine for last 7 days.

7. History of present illness (Cont.)
During the course of his illness, she gave no history of neck pain,
prolonged fever, unexplained weight loss, anorexia, cough, hemoptysis,
prolong use of steroid or close contact with known TB patient.

8. History of present illness (Cont.)
With the above complaints, she visited Sir Salimullah Medical college
hospital and then referred to Neurosurgery department ,DMCH for
better management.

9. Associated illness
 She has no history of Diabetes, Hypertension, any heart, kidney,
lung disease

10. Past medical history
She has no H/O major childhood illness, previous surgery,
accident or injury.

11. Immunization History
 Vaccinated as per EPI schedule and 3 doses of covid vaccine

12. Family history
Nothing significant. Girl of a non consanguineous married parents. She
have 4 sons and 1 daughter . Other family members are leading a
healthy life.

13. Personal history
 She is non smoker, non alcoholic, but betel nut chewer

14. Socio economic history
 She belongs to a family with low socio-economic condition

15. Drug history
 Nothing significant.

16. General Physical Examination
 Appearance: Vacant
 Body built: Below Average
 Less Co-operative
 Decubitus: On choice
 Nutritional status: Below
Average
 Pulse: 72 b/m
 BP: 110/80 mmHg
 Temp: Not raised
 RR: 16/m
 Jaundice
 Clubbing
 Cyanosis
 Anemia
 Leukonychia
 Edema
 Dehydration
 Koilonychia
 Lymphadenopathy
 Catheter in situ
No abnormality
detected

17. Systemic Examination
• Cardiovascular System-No abnormality detected
• Respiratory System-No abnormality detected
• Alimentary System-No abnormality detected

18. Nervous System Examination
 Higher psychic function: Normal
 Memory: Intact
 GCS: E₄V₅M₆
 Gait: can’t walk
 Right handed person
 Speech : Normal
 No sign of cerebellar dysfunction
 No sign of meningeal irritation

19. Cranial Nerve Examination
• Olfactory nerve - Normal
• Optic nerve - Right Left
Visual acuity 6/6 6/6
Visual field No restriction No restriction
Colour vision Intact Intact
Fundoscopy Normal Normal

21. Oculomotor, Trochlear & Abducens nerve
• Diplopia – Absent
• Nystagmus - Absent

22. Trigeminal nerve (V)
 Sensory: Intact to all modalities in all the three
divisions.
 Corneal Reflex: Normal (B/E)
 Motor (Muscles of Mastication): Intact Bilaterally
 Jaw Jerk: Absent

23. Facial nerve (Vll)
• Motor function –
1. Frontalis / Wrinkling of fore head – Intact
2. Orbicularis occuli / Closing of eye – Intact
3. Buccinator / Whistle blowing – Intact
4. Risorius/ Showing of teeth - Normal
5. Platysma / Clenching of neck - Normal
• Taste sensation – Intact

24. Vestibulocochlear nerve (Vlll)
Vestibulocochlear nerve -

25. Glossopharyngeal and Vagus nerve

26. Accessory Nerve (XI)
Deviation of Tongue Absent
Atrophy of tongue muscle Absent
Fasciculation Absent

27. Frontal Lobe Functions
 Precentral gyrus: Mono or Hemiplegia – Present
 Broca’s area: Motor dysphasia – Present
 Supplementary motor area: Paralysis of head & eye movement to
opposite side – Absent
 Paracentral lobule: loss of cortical inhibition to bowel & bladder
sphincter – Incontinence of urine was present

28. Pre-Frontal areas
Orbitofrontal Syndrome
Disinhibition Absent
Poor Judgment Absent
Emotional lability Absent
Frontal Convexity Syndrome
Poor Abstract thought Absent
Indifference Absent
Apathy Present
Medial Frontal Syndrome
Sparse verbal output Present
Incontinent Present
Akinetic Absent

29. Parietal lobe functions
FUNCTIONS FUNCTIONS
Postural Sensation Normal Geographical Agnosia Absent
Sensation Of Passive Movement Normal Constructional Apraxia Absent
Accurate Localization Of Light Touch Intact
Dressing Apraxia
Absent
Two Point Discrimination Normal
Finger Agnosia
Absent
Astereognosis Absent Left-right Confusion Absent
Perceptual Rivalry Absent Agraphia Absent
Wernicke’s Dysphasia Absent Acalculia Absent
Anosognosia Absent
Visual Field Defect
(inferior quadrantopia)
Absent

30. FUNCTIONS INTERPRETATION
Cortical deafness Absent
Amusia Absent
Auditory Hallucination Absent
Memory
Intact
Olfactory Hallucination Absent
Aggressive or antisocial Behavior Absent
Visual Field Defect (superior quadrantopia) Absent
Temporal Lobe functions

31. Motor examination of upper limb
Right Left
Tone Normal Normal
Bulk Normal Normal
Fasciculation Absent Absent
Power Elbow flexors 4 5
Wrist extensors 4 5
Elbow extensors 4 5
Finger flexors 4 5
Finger adductors 4 5
Jerks Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Hoffman Negative Negative

32. Motor examination of Lower limb
Right Left
Tone Normal Normal
Bulk Normal Normal
Fasciculation Absent Absent
Power Hip flexors 4 5
Knee extensors 4 5
Ankle Dorsiflexion 4 5
EHL 4 5
FHL 4 5
Jerks Knee ++ ++
Ankle ++ ++
Planter Flexor Flexor
Clonus Absent Absent

33. Sensory Examination
• Sensory examination reveals
pain, touch, pressure, vibration,
proprioception intact.

34. Examination of spine
No scoliosis, gibbus, kyphotic deformity
No visible midline or paraspinal mass
Overlying skin condition –normal
Local temperature –not raised
Focal tenderness is absent

35. Provisional diagnosis

36. Provisional diagnosis
• A case of left Supratentorial Space occupying lesion

37. Differential Diagnosis
 Glioma
 Meningioma
 AVM
 Arachnoid cyst

38. INVESTIGATIONS

39. CT Scan of the head

41. MRI of the brain with contrast

42. MRI of brain T1WI with multiple axial section

43. MRI of the brain T2WI with multiple axial section

44. MRI of the brain (T1W1) with multiple Sagittal section

45. MRI of the brain (T2W1) with multiple coronal section

46. MRI of the brain with FLAIR

47. MRI of the brain (DWI)

48. T1W1 multiple axial section with contrast

49. T2WI Multiple axial section with contrast

50. MRI of the brain with multiple coronal section with contrast

51. Clinico radiological diagnosis
A case of left frontoparietal Arachnoid cyst

52. Surgical Plan
Left fronto -temporal craniotomy and marsupialization of
cyst.

53. Positioning
•Supine position
•The neck rotated towards left.
•Head should be placed above heart level.
•Padding should be placed at bony
prominence

54. Incision
Horse shoe incision

55. Craniotomy
Making 2 or 3 burr hole centering the cyst & each burr hole will be
connected.
The dura will be dissected off from inner table with penfield - 3
dissector.

56. Dural Incision & Devascularization
 Devascularization of the branches of the
middle meningeal artery around the dura.
 Dural incision in circular fashion 1cm
away from craniotomy margin .

57. Cyst Removal
 Microsurgical marsupialization of cyst.

58. Hemostasis
 Bipolar
 Gelatin sponge
 Fibrillar / Surgicel

59. Closure
 Closure of dura mater necessarily implies application of graft.
 For this purpose, local tissue can be used such as galea
aponeurotica, pericranium, fascia lata or synthetic dural
substitute.
 Water tight fashion dural closure will be ensured.

60. Complications
Per-operative:
 Excessive hemorrhage during craniotomy & cyst removal
 Injury to underlying cortex
 Cerebral contusion, swelling or infarction
 Air embolism

61. Post-operative:
 Onset of new neurological deficit.
 Seizure
 CSF leakage
 Pseudomeningocele
 Meningitis
 Wound infection