Preparation for Surgery for Atretic Encephaloceles in Children - The ISPN Guide to Pediatric Neurosurgery

Preparation for Surgery for Atretic Encephaloceles in Children

Indications for Surgery

Atretic encephaloceles may be treated conservatively. Surgery is generally indicated for the following reasons (16):

  • Diagnosis: Congenital midline subscalp lesions usually provoke parental concerns about their nature.
  • Relief of pain: Pain that either is spontaneous or is provoked by physical contact occurs in some patients due to stretching of the dura mater.
  • Avoidance of infection: The superficial location of lesions can lead to ulceration and infection. CSF leakage from the lesion has seldom been reported.
  • Erosion with hemorrhage: Rarely, an atretic encephalocele might undergo superficial erosion with bleeding (16, 28).

Preoperative Orders

  • Antibiotics: Antibiotic prophylaxis should be considered.  Most neurosurgeons use a perioperative dose delivered around the time of induction of anesthesia prior to skin incision. Some also use postoperative antibiotics, although their efficacy has not been proven.
  • Fasting: Fasting is instituted according to the patient’s age.
  • Shaving: Atretic encephaloceles are best delimited by direct eye vision, and thus the hair usually is shaved in a small surface around the lesion.

Anesthetic Considerations

No special anesthetic measures are needed. The main concerns are as follows:

  • Air embolism: The possibility of air embolism is very rare.
  • Blood loss: Due to the attachment of the lesion to the dura mater and sagittal sinus, the possibility of copious hemorrhage should be anticipated.
  • Associated system anomalies: Special precautions must be contemplated in cases with associated systemic anomalies (e.g., cardiac or renal malformations).

Devices to Be Implanted

  • Shunt material if hydrocephalic: In some patients with atretic encephalocele and hydrocephalus, a ventriculoperitoneal shunt may be placed during the same anesthetic procedure.
  • No cranioplasty: There is no need for cranioplasty at this stage.

Ancillary/Specialized Equipment

  • Doppler: An echo-Doppler can be used intraoperatively to locate the position of the sagittal sinus.