case_images: PMC9163400_01
case_images: Initial non-contrast CT of the head demonstrating left temporal cyst.
case_images: fneur-13-893767-g0001.jpg
case_images: PMC9163400_01_fneur-13-893767-g0001.jpg
case_images: F1
case_images: 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.
case_images: 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).
case_images: fneur-13-893767-g0002.jpg
case_images: PMC9163400_01_fneur-13-893767-g0002.jpg
case_images: F2
case_images: 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).
case_images: 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.
case_images: fneur-13-893767-g0003.jpg
case_images: PMC9163400_01_fneur-13-893767-g0003.jpg
case_images: F3
case_images: 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).
case_images: Non-contrast CT scan demonstrating improved cerebral edema on day of EVD removal.
case_images: fneur-13-893767-g0004.jpg
case_images: PMC9163400_01_fneur-13-893767-g0004.jpg
case_images: F4
case_images: The EVD was then removed at 13 days post-insertion (Figure 4).