Repair of giant occipital encephaloceles with microcephaly secondary to massive brain herniation

Giant Occipital Encephalocele: A Case Report and Literature Review

Background

Protrusion of cerebrospinal fluid and meninges is called meningocele. Meningoencephalocele is a protrusion of neural tissue and meninges. The incidence of an Encephalocele is 1 in every 5000 live births. Anterior encephalocele is more common in men, while occipital encephalocele is seen in 70% of women. In a large encephalocele, the head size is small. Encephaloceles can occasionally be very large and are called giant encephaloceles. Occipital encephaloceles accounted for 80% to 90% of encephalocele cases in the western hemisphere. Encephaloceles vary in size and content. Various factors affecting the prognosis of patients with occipital encephalocele. Among them: extent, amount of brain tissue in the sac with or without Dural venous sinuses in the sac, with the brain or occipital lobe with hydrocephalus or presence of ventricles. Rarely, the sagittal and transverse sinuses are adjacent to the sac.

Case Presentation

This is a case of an 8-month old male infant born to a mother who had no regular antenatal care. After the baby presented with progressively increasing posterior head mass which is cystic, transilluminating, tender and size is 40cmX35cm imaging demonstrated small brain tissue mainly part of right occipital lobe with most of the sac being occupied by cerebrospinal fluid. Repair done and dysplastic brain tissue resected then healthy-looking brain tissue and Dural sinuses reduced to the skull, then patient stayed in the hospital and closely followed for hydrocephalus for seven days and discharged with no hydrocephalus and no neurologic deficit.

The outcome of surgical management for the patient with giant occipital encephalocele: a case illustration and systematic review

PURPOSE

Occipital encephalocele (OE) is one of congenital malformation of the central nervous system. However, giant OE, mostly defines as bigger-than-head OE, is extremely rare and carries a worse prognosis. Here, we presented our systematic review of the management of the giant OE and illustrated our case.

METHOD

The systematic review was carried out under PRISMA guidelines. Publications were searched under "occipital encephalocele" from 1959 to April 2021. Our primary area of interest was the outcome of patients who have undergone surgery for giant OE. Variables of interest included age, sex, size of the sac, presentations, associated anomalies, management, outcome, and follow-up period were collected.

RESULT

We collected 35 articles, consisting of 74 cases (including 1 case from our illustrative case), to perform a systematic review. The mean age at the time of surgery was 3.53 ± 8.22 months. The mean circumference of the sac was 52.41 ± 18.6 cm. The three most common associated anomalies were microcephaly, corpus callosal agenesis/dysgenesis, and Chiari malformation. After the surgery, survival was reported in 64 (90.1%) patients. Postoperative complications were reported in 14 cases (16 events). Age above 1 month at the time of surgery was significantly associated with survival (p = 0.02) but not with complication (p = 0.22). In contrast, the type of surgery was not associated with survival (p = 0.18) or complications (p = 0.41).

CONCLUSION

Despite a rare condition with a poor prognosis, our reported case and systematic review revealed promising outcomes of surgery regardless of surgical strategies, especially in patients older than 1 month. Thus, appropriate planning is essential for the treatment of this condition.

Giant occipital encephalocele complicated with obstructive hydrocephalus: A case report

Introduction

and importance: An encephalocele is a type of congenital neural tube defect defined by herniation of intracranial contents via a cranial defect. When an encephalocele is greater than the size of the head, it is referred to as a "giant encephalocele." The occurrence of encephalocele has been documented to be 1–4 instances per 10,000 live births. Surgery is challenging.

Case presentation

A 1-month-old baby boy sustained a huge swelling on the back of his head since birth, and it increased gradually over time. On examination, he had a huge occipital swelling measuring about 20 × 15 × 17 cm in size. A diagnosis of giant occipital encephalocele was established. Surgical excision and repair was done. After 1 month, he developed obstructive hydrocephalus and a ventriculo-periotoneal shunting was performed. On regular follow-up, he is in a good state of health.

Discussion

Surgery imposes challenges for the anaesthesiologists and neurosurgeons due to its complex site, enormous size, intraoperative blood loss, and prolonged anaesthesia. A team approach is necessary for its successful treatment.

Conclusions

Based on our experience, we would like to deliver following recommendations in the surgical management of giant encephalocele. Surgery should be done quickly to ensure good prognosis. Proper positioning, efficient intubation, infections and sepsis control should be emphasized. Also, fortification of food with folic acid, as well as increased education and awareness of women on the need for antenatal care may also decrease the risk of this disease.

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An encephalocele is a type of congenital neural tube defect.

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Surgery imposes challenges for the anaesthesiologists and neurosurgeons.

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A team approach is necessary for its successful treatment.

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Proper positioning, efficient intubation, infections and sepsis control should be emphasized.

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Fortification of food with folic acid may also decrease the risk of this disease.

Hydrocephalus associated with occipital encephalocele: surgical management and clinical outcome

Background

Encephaloceles are cystic congenital malformations in which central nervous system (CNS) structures, in communication with cerebrospinal fluid (CSF) pathways, herniate through a defect in the cranium. Hydrocephalus occurs in 60–90% of patients with occipital encephaloceles.

Objective

Assessment of the surgical management of hydrocephalus associated with occipital encephalocele and its effect on the clinical outcome.

Methods

Between October 2015 and October 2019, a retrospective study was conducted on seventeen children with occipital encephaloceles who were operated upon. The presence of progressive hydrocephalus was determined by an abnormal increase in head circumference and an increase in the ventricular size on imaging studies. A ventriculoperitoneal (VP) shunt was applied in patients who had hydrocephalus. The clinical outcome was graded according to the developmental milestones of the children on outpatient follow-up visits.

Results

The mean age at surgery was 1.6 (range, 0–15) months. There were ten girls (58.8%) and seven boys (41.2%). Ten encephaloceles (58.8%) contained neural tissue. Ten patients (58.8%) had associated cranial anomalies. Eleven children (64.7%) had associated hydrocephalus: four of them (36.4%) diagnosed preoperatively, while seven children (63.6%) developed hydrocephalus postoperatively. Ten of them (90.9%) were managed by VP shunt. All children with hydrocephalus had some degree of developmental delay, including six (54.5%) with mild/moderate delay and five (45.5%) with severe delay. Half of the patients (50%) of the children with occipital encephalocele without hydrocephalus had normal neurological outcome during the follow-up period (p value= 0.034).

Conclusions

Occipital encephalocele is often complicated by hydrocephalus. The presence of hydrocephalus resulted in a worse clinical outcome in children with occipital encephalocele, so it can help to guide prenatal and neonatal counseling.

Fetal surgery for occipital encephalocele

OBJECTIVE

In this study, the authors retrospectively reviewed two cohorts of patients with occipital encephalocele (OE) and demonstrate the technical aspects of an innovative and unprecedented method for fetal OE correction.

METHODS

This was a cross-sectional retrospective study of 22 patients who underwent surgery from July 2012 to July 2018. The inclusion criteria for participants were a gestational age between 19 weeks and 27 weeks, a maternal age ≥ 18 years, a normal fetal karyotype, the presence of microcephaly, and a cystic hernial sac with the cystic component accounting for more than 80% of the total volume, which was larger than 10 ml. The fetuses with OE and microcephaly underwent intrauterine repair. The exclusion criteria were the presence of a fetal anomaly not associated with OE, chromosomopathy, presence of the brainstem inside the hernial sac or venous sinuses inside the herniated content, the risk of premature birth, placenta previa, and maternal conditions that would constitute an additional risk for fetal and maternal health, as well as refusal for fetal surgery. The authors reviewed the potential for microcephaly reversal and the long-term neurocognitive development.

RESULTS

The authors report the cases of 9 fetuses with OE and microcephaly who underwent intrauterine OE repair at gestational ages of less than 27 weeks (fetal group). One case selected for fetal surgery also presented with placental abruption. All patients who underwent the fetal operation had microcephaly reversal, and 3 patients required ventriculoperitoneal shunting in the 1st year of life. The authors reviewed the cases of 12 patients who underwent postnatal repair. In 10 cases, fetal surgery was refused (postnatal group), and in 2 cases, the inclusion criteria for fetal surgery were not met. The authors evaluated the neurocognitive development of the patients with the Bayley Scales of Infant Development II. The median score for the fetal group was 98.7, and that for the postnatal group was 27.8.

CONCLUSIONS

The intrauterine repair of OE may stop the progression of encephalocele sac herniation and result in microcephaly reversal. The fetal group had a better cognitive outcome than the postnatal group. The technique required to correct this defect is feasible for those with previous experience in the correction of fetal myelomeningocele. However, more studies are needed to ensure the efficacy of this procedure.

Giant Encephalocele in Sokoto, Nigeria: A 5-Year Review of Operated Cases

OBJECTIVE

Encephalocele is a common congenital malformation of the central nervous system; however, giant encephaloceles are rare. The use of folic acid supplementation and termination of pregnancies, which are prenatally diagnosed with encephaloceles and other congenital malformation of the central nervous system, has significantly reduced the occurrence of this type of congenital malformation, especially in developed countries.

METHODS

This was a retrospective review over a 5-year period from January 2006 to December 2010 at the Department of Neurosurgery, Regional Centre for Neurosurgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. The records of patients with giant encephalocele were retrieved from the case notes of patients who had excision and repair for encephalocele.

RESULTS

Seventy-three patients had excision and repair of encephalocele over the study period. However, the records of only 50 patients were retrieved. Fourteen (28%) of the 50 whose records were retrieved had giant encephalocele. There were 4 male and 10 female patients (1:2.5). Thirteen (92.9%) had the lesion located in the occipital region, whereas in 1 patient (7.1%) the lesion was at the vertex. Three (21%) of the cases had microcephaly, 1 (7.1%) had macrocephaly, and 1 (7.1%) developed postoperative hydrocephalus. The average size of defect was 2.43 cm, and the size of the lesion ranged from 12 × 6 cm to 40 × 50 cm. The average maternal age was 20.3 years (n = 6), and the paternal age was 29 years (n = 4). Four out of 7 (57%) mothers had febrile illness in early pregnancy. Seven out of 10 patients (70%) did not have antenatal care.

CONCLUSIONS

This condition is more common in children conceived during the period when farm products are yet to be harvested, and whose mothers did not attend antenatal care visits. It is recommended that mothers should be educated on the necessity of preconception folic acid. Implementation of a national strategy on food fortification is also advised. We recommend surgery after the first month of life to reduce poor early postoperative outcomes. In developing countries and centers with suboptimal pediatric intensive care units, surgical intervention is preferred after the first month of life with good temperature control, adequate fluid replacement following rupture of the sac, blood transfusion availability, and, only if necessary, complex cranial reconstruction.

Neurosurgical Interventions for Occipital Encephalocele

Aims and Objectives:

The aim of this study is to find the outcome of repair and resection of the occipital encephalocele.

Study Design:

Case series.

Materials and Methods:

The clinical data of fifty consecutive occipital encephalocele patients were retrieved from medical records including operative notes, postoperative follow-up visits, and postsurgical complications were noted for analysis from November 2009 to November 2013 at the Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. All patients were assessed by computed tomography scan, magnetic resonance imaging brain, and ultrasound when needed. Physician's assessment, physical examination, and his/her questions to the family at follow-up were used as a tool to determine if there was a developmental delay rather than quantitative analysis like hydrocephalus questionnaires. Patients who developed complications and delayed milestone were regarded as no improvement and those who did not develop complications and achieved appropriate milestone were regarded as improved at 18 months follow-up.

Results:

Of 50 patients, 17 were males and 33 were females. The average age at presentation was 2.4 months. 16 (32%) patients had increased head circumference and hydrocephalus, 2 (4%) had associated Dandy–Walker cyst, 3 (6%) developed developmental delays, and 8 (15%) had a seizure disorder. None of our patients had neurological deficits. The size of the sac ranged from 2 cm × 3 cm to 27 cm × 15 cm. 9 (18%) patients were admitted with the complication of sac rupture and 2 (4%) patients sac ruptured after admission. Only one patient (2%) had a cerebrospinal fluid leak postoperatively that was repaired primarily without patch graft or dura seal while 4 (8%) developed hydrocephalus after repair of the sac which was treated with placement of ventriculoperitoneal shunt. One (2%) patient did not recover from anesthesia and expired.

Conclusion:

Encephalocele is commonly seen in the practice of neurosurgery in the world as well as in Pakistan. Modern neuroimaging, neurosurgical techniques, and neonatal neurological intensive care have greatly improved morbidity and mortality in the care of encephalocele.

Matriderm for Management of Scalp Necrosis Following Surgical Treatment of Giant Parietal Encephalocele

BACKGROUND

Management of encephaloceles is challenging when massive brain herniation is present. In such instances, an expansile cranioplasty may be attempted so as to preserve some herniated brain tissue. Complications such as wound dehiscence, cerebrospinal fluid leak, and scalp necrosis are postoperative concerns. The treatment of scalp necrosis with dural and brain exposure is certainly a challenge due to the complexity of flap techniques in such a young age. Herein we describe the use of a novel technique for the management of a scalp necrosis and dehiscence in an infant.

CASE DESCRIPTION

A patient with a giant parietal encephalocele and massive brain herniation underwent an expansile cranioplasty. A large scalp necrosis ensued as a complication and later progressed to a suture dehiscence despite a new surgical intervention, with resultant brain exposure. A scalp reconstruction was subsequently performed using an artificial dermal substitute, laid directly onto the brain, followed by a split-thickness skin graft. We observed a rapid engraftment, without any further complications, with an acceptable cosmetic result in the long-term follow-up.

CONCLUSION

A simple technique, such as the use of an artificial dermal matrix with simultaneous split-thickness skin graft, may be an effective treatment for the repair of scalp defects, even when coverage of exposed brain tissue is necessary, when no other techniques are found to be suitable.

A Rare Triad of Giant Occipital Encephalocele with Lipomyelomeningocele, Tetralogy of Fallot, and Situs Inversus

Giant encephalocele is an uncommon congenital anomaly with very few published reports available in the English literature. Tetralogy of Fallot associated with situs inversus is also infrequently reported. To our knowledge there are no published reports of an association between giant encephalocele and Tetralogy of Fallot. The additional finding of situs inversus results in a rare pathologic triad, not heretofore described.

Parietal and occipital encephalocele in same child: A rarest variety of double encephalocele

An encephalocele is a protrusion of the brain and/or meninges through a defect in the skull. Based on the location of the skull defect they are classified into sincipital, basal, occipital or parietal varieties. Occurrence of more than one Encephalocele in a patient is very rare and very few cases of double encephalocele are reported. We report an interesting case where a parietal and an occipital encephalocele were present together. The patient was a 2 months boy who was brought to us with complaints of two swelling on the scalp since birth. Neuroimaging studies confirmed it to be a case of double encephalocele. The rarity of the findings prompted us to report this case. The presentation and management of the case along with and review of the relevant literature is presented.

Novel neurodevelopmental disorder in the case of a giant occipitoparietal meningoencephalocele

Giant occipitoparietal encephaloceles are rare forms of neurodevelopmental defects whose etiologies remain uncertain. Their occurrence can lead to variable neurological outcomes depending on the extent of cerebral cortex involved and the ability to repair the defect. In addition, encephaloceles may be associated with various genetic syndromes and familial inheritance. Here, the authors describe a unique constellation of malformations associated with the case of a giant occipitoparietal meningoencephalocele with herniation of cortical tissue and continuity with the ventricular system. The patient had a cleft lip and palate, hemivertebrae of the thoracic spine, a patent ductus arteriosus, a ventricular septal defect, and coarctation of the aorta. To identify the genetic underpinnings of these malformations, fluorescence in situ hybridization and microarray analysis were performed and revealed an 80.65-kb gain within chromosome band 2p11.2. Duplications of this region involving RMND5A, whose product contains a C-terminal to lis homology (LisH) domain, have not previously been associated with a defined phenotype but may present insight into encephalocele formation. Surgical repair and follow-up for the neurological malformations are also discussed.

Bipolar duraplasty: a new technique for reducing transcranial cerebral herniation to allow for definitive cranioplasty

Large, full-thickness calvarial defects cause increased brain tissue compliance, often resulting in transient, transcranial herniation in the setting of normotensive intracranial pressures. Cranioplasty serves to protect the cerebrum from external injury, provide an aesthetic contour, and alleviate neurological symptoms. Traditional options for management include head elevation, osmotic diuresis, mild hyperventilation, durotomy with closure following fluid evacuation, expansile cranioplasty, lobectomy, and procedure abortion with prolonged helmet therapy. Patients treated conservatively with helmet therapy commonly are noncompliant and sustain repeated minor trauma to unprotected cerebral contents. Furthermore, recent literature suggests that early cranioplasty may improve outcomes and reduce costs. The authors present a novel solution, bipolar duraplasty, which allows safe, transient reduction of normotensive parenchymal herniation using bipolar electrocautery. The dura of the herniated sac is cauterized using a low-set, bipolar current in a series of sagittal and coronal lines, resulting in immediate contraction and reduction allowing for definitive cranioplasty. This new method was used in a patient with a 30-cm(2) frontal bone defect following resection of a right falcine atypical meningioma. In this scenario, bipolar duraplasty was performed free of complication, and the patient has remained asymptomatic and greatly satisfied for 1 year since the procedure. This technique might facilitate earlier cranioplasty, could be applied to a wide range of patients, and may afford better neurological outcomes at a reduced cost.

Expansile cranioplasty for massive occipital encephalocele

OBJECTIVE

This report highlights the management of infrequently encountered massive occipital encephaloceles with herniation of large amount of apparently functional cortex into the encephalocele sac.

MATERIALS AND METHODS

Two children with giant occipital encephaloceles with herniation of significant brain parenchyma into the encephalocele sac were managed with expansile cranioplasty and reconstruction of the calvarial defect with autologus bone graft harvested from the adjacent parietal region.

CONCLUSIONS

Giant occipital encephaloceles with significant brain parenchyma in the encephalocele sac can be considered for preservation of the herniated parenchyma and expansile cranioplasty.

Surgical closure and reconstruction of a large occipital encephalocele without parenchymal excision

INTRODUCTION

Encephalomeningocele is a herniation of the brain and meninges through a congenital bone defect resulting from the failure of normal midline fusion of the cranial neural tube. Various sites are possible; however, among Caucasians more than 70% of encephaloceles are located on the occipital/posterior part of the cranium. Usually they contain degenerative cerebral cortex, which is often excised during surgical closure of the defect. Techniques to preserve the herniated brain tissue have been described, but they focus on increasing the intracranial cavity by ventriculomegaly and retracting the encephalocele into new intracranial space in a second stage, as a result of hydrocephalic treatment.

TECHNICAL REPORT

The authors report a well-documented newborn with a large encephalocystocele of the left occipital lobe. This encephalocele included the left lateral ventricle and a part of the cerebellum, and was covered with allopathic skin. Initially the cystic portion was removed so that a partial reduction of the encephalocystocele was achieved. Six months later, the surgical closure of the defect was performed, with preservation of the occipital and cerebellar parenchyma, by incising the tentorium and retracting the cortex to the newly created infratentorial space. The bony defect was covered with autologous osseous graft harvested from parietal bone and reconstructed.

OUTCOME

In the long-term follow-up after 13 years, the child has preserved visual function.

Ventricular volume reduction technique--a new surgical concept for the intracranial transposition of encephalocele

The authors propose a new operative technique for the intracranial transposition of an encephalocele by using the associated hydrocephalic state. In the first stage, the intracranial pressure buffering effect of the encephalocele sac is reduced by the closing of the dural defect. The repaired dural defect allows intraventricular pulse pressure to produce ventriculomegaly. In the second stage or in infants with hydrocephalus, the extracranially herniated brain is transposed into the intracranial cavity during ventricular shunting with appropriate drainage of cerebrospinal fluid.