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.