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Encephalocele: A Rare Contraindication to Neuraxial Technique
Abstract Number: F 48
Abstract Type: Case Report/Case Series
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 . Hydrocephalus, developmental delay, seizures
and vision problems are present in at least 60% of cases and encephalocele is often associated
with facial defects , which may lead to difficult intubation . 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
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.