Ruptured Dermoid/Epidermoid Cyst can mimic acute cerebellar hemorrhage and early surgical intervention can improve neurological outcome.

CNS epidermoid or dermoid cysts are benign, slow-growing lesions and can be congenital or acquired. They arise from ectopic ectodermal cells that are retained within the neural groove during early gestation. Nearly 5% have atypical appearance.

Case report and review of literature

Case Report:

56-year-old, woman with hypertension, hypothyroidism, depression and migraine headaches presented to ICU for acute cerebellar hemorrhage complicated by hydrocephalus manifested by 2-days history of severe headaches with sensory phobias, nausea, vomiting, and difficulty walking. Patient was intubated due to decreased level of consciousness. CT head initially revealed 5.5x5.2x4.0 (57 cc volume) acute hemorrhage in cerebellum/4th ventricle with acute hydrocephalus. Vascular malformations were ruled out. Suboccipital craniotomy with resection/cavity evacuation of fluid collection was done and it showed light brown malodourous fluid collection and calcifications initially concerning for brainstem abscess. Patient was started on broad spectrum antibiotics. Cultures and pathology was sent. Pathology report showed dermoid or epidermoid cyst (Keratin debris with resolving hemorrhage and focal necrotic debris) and cultures were negative. MRI after the surgery showed postsurgical changes without any diffusion restriction. Patient improved drastically and was eventually discharged home in a week.

Intracranial epidermoid and dermoid tumors are benign lesions. Early surgical intervention is advocated to prevent the risk of serious complications and completed resection is indicated as subtotal resection carries a high incidence of recurrence plus rare possibility of carcinomatous degeneration of remnants. Ruptured intracranial cysts can not only cause headache, seizures but also cerebral infarction, hydrocephalus, chemical meningitis, and even death.