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///2013 Abstract Details
2013 Abstract Details2019-08-02T16:57:45-05:00

Encephalocele: A Rare Contraindication to Neuraxial Technique

Abstract Number: F 48
Abstract Type: Case Report/Case Series

Thomas T Klumpner M.D.1 ; Rachel M Kacmar M.D.2; Nicole Higgins M.D.3

Introduction: Fronto-ethmoidal encephaloceles are a rare occurrence in North America and are

most commonly diagnosed in utero or shortly after birth. Congenital in nature, pathogenesis may

be due to a late neurodevelopmental defect [1]. Hydrocephalus, developmental delay, seizures

and vision problems are present in at least 60% of cases and encephalocele is often associated

with facial defects [2], which may lead to difficult intubation [3]. To our knowledge there are no

reported cases of this diagnosis in pregnancy.

Case: 31 y/o G9P1 at 34.1 EGA with chronic HTN, epilepsy, obesity (BMI 41), and medication

non-compliance presented for cesarean delivery due to non-reassuring NST and worsening HTN.

Her pregnancy was complicated by seizure at 20 wks EGA leading to the discovery of a 3.9cm

by 2.9 cm encephalocele extending caudally from the cribriform plate and filling the posterior

aspect of the right nasal cavity and a repeat cesarean section under general anesthesia was

planned. The patient was brought to the OR and her BP was found to be 230/120 and a pre-

induction a-line was placed. A nicardipine drip was started and labetalol, esmolol and nicardipine

boluses were initiated. Following RSI with propofol and succinylcholine, the patient’s airway

was topicalized with LTA lidocaine and intubated using videolaryngoscopy. After delivery of the

fetus, oxytocin was started at 36 U/hr for mild uterine atony. No additional uterotonic agents

were necessary. Goal BP of 150-170 systolic was maintained with nicardipine, labetalol, volatile

anesthetic and opioid. Prior to emergence a bilateral transversus abdominis plane (TAP) block

was performed for post-operative analgesia. A slow, controlled emergence with divided doses

of hydromorphone and a nicardipine infusion allowed a hemodynamically stable extubation

without coughing. The nicardipine was titrated off over the next several hours and the patient was

discharged on POD #4.

Discussion: Although this patient had a previous neuraxial anesthetic for cesarean delivery

without incident, and no outward signs of elevated intracranial pressure apart from severe,

intractable hypertension, the risk of dural puncture with subsequent loss of CSF pressure

and herniation was determined to outweigh the benefit of avoiding general anesthesia. The

pediatric literature contains reports of sudden cardiac arrest from decompression of CSF

from encephalocele sacs [4,5]. Using a combination of anesthetic techniques we avoided

neuraxial trespass and increases in ICP while maintaining hemodynamic stability in this uniquely

complicated patient.

1. Hoving EW. Childs Nerv Syst 2000;16(10-11):702-6.

2. Stoll C et al. Genet Couns 2007;18:209-215.

3. Mahajan et al. J Neurosurg Anesthesiol 2011;23(4):352-6.

4. Ganjoo P, Kaushik S. J Neurosurg Anesthesiol 1993;5:137-138.

5. Rickett CH, et al. Int J Legal Med 2001;114:331-337.

SOAP 2013