Pial Laceration from a Dural Suture Causing Devastating Neurological Deficits

A 39-year-old man received empiric treatment for pulmonary tuberculosis (TB). After developing sensory seizures he was restarted on anti-TB drugs when a brain MRI showed a 4.3 cm left parietal enhancing lesion with extensive edema. After TB treatment, imaging showed a reduction in size and edema. Later, he developed headache and seizures, and MRI showed recurrent edema and an enlarging lesion. Neurosurgery decided to biopsy the lesion to obtain a diagnosis. At craniotomy, a frozen section was reported as granulomatous inflammation. However, he returned postOP with a new right hemiparesis and MRI showed a cystic lesion under the motor cortex, with no enhancement. Craniotomy was performed and the lesion was excised and exploration revealed that one of the dural stitches had lacerated the brain as a cause of the cyst formation. The case differential and management is discussed in detail.