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Anesthesia Management in Massive Occipital Meningoencephalocele with Chiari III Malformation: A Case Report
Arief Cahyadi1,2, Riyadh Firdaus2, Hansen Angkasa2
1Department of Anestesiology, Univesitas Padjajaran, Hasan Sadikin General Hospital, Bandung, Indonesia.
Insights
This case report details the anesthetic management of a rare Arnold-Chiari malformation type III (CM III) in a 16-month-old girl with a massive occipital meningoencephalocele. Anesthetic challenges included difficult airway and hemodynamic instability during surgery.
Area of Science:
- Neurosurgery
- Pediatric Anesthesiology
- Medical Case Reports
Background:
- Arnold-Chiari malformation (ACM) involves brain displacement into the spinal canal, potentially causing hemodynamic distress.
- Arnold-Chiari malformation type III (CM III) is a rare, severe congenital anomaly necessitating early diagnosis and intervention.
- Massive occipital meningoencephaloceles associated with CM III present significant surgical and anesthetic challenges.
Observation:
- A 16-month-old girl with a massive occipital meningoencephalocele, suspected CM III, faced anesthetic difficulties including a compromised airway and obesity.
- Intraoperative events included laryngospasm, desaturation requiring a laryngeal mask airway, and significant blood pressure fluctuations during cerebrospinal fluid drainage and brain tissue resection.
- The patient exhibited preoperative lethargy, abnormal vital signs, and postoperative inability to extubate due to insufficient brainstem reduction and autonomic dysfunction.
Findings:
- Anesthetic management for massive occipital meningoencephalocele with CM III requires careful airway control and avoidance of cervical manipulation to prevent increased intracranial pressure.
- Hemodynamic instability, including hypotension during CSF drainage and bleeding during resection, necessitates aggressive fluid and blood product resuscitation.
- Postoperative extubation was precluded by persistent brainstem compression and significant autonomic dysfunction, highlighting the complexity of this condition.
Implications:
- This case underscores the critical need for meticulous anesthetic planning and execution in patients with complex craniovertebral anomalies like CM III.
- Effective management strategies involve anticipating and mitigating potential complications such as airway compromise, hemodynamic instability, and neurological deficits.
- Further research into anesthetic protocols for rare pediatric neurosurgical conditions is warranted to improve patient outcomes.
Abstract:
Arnold-Chiari malformation is a displacement of the brain into the spinal canal, often leading to hemodynamic distress. Arnold-Chiari malformation type III (CM III) is a rare and severe type that requires early detection to prevent complications. We aim to report this rare presentation of CM III. A 16-month-old girl with a massive tumor of the occiput suspected to be a meningoencephalocele with CM III was referred to the neurosurgery department. The patient was assessed with class 3 American Society of Anesthesiologist classification, posed challenges due to a difficult airway and the presence of a meningoencephalocele. The patient was scheduled for an elective surgery. Preoperative, the patient was lethargic with an abnormal heart rate and blood pressure. Induction was performed while preserving spontaneous ventilation, but was assisted by an oropharyngeal airway due to a short neck and obesity. The patient later developed laryngospasm thus, muscle relaxant and propofol were administered. A rescue laryngeal mask airway was inserted due to desaturation. Intubation was performed with video laryngoscope. When the surgeon opened the cele and removed the cerebrospinal fluid, the blood pressure began to decline. Resection of brain tissue caused the patient started to bleed, fluid and blood products were administered. At the end of surgery, the patient had stable hemodynamics and was transferred to the pediatric intensive care for monitoring. In patients with massive occipital meningoencephalocele and CM III, anesthetic management requires smooth intubation and prevention of excessive manipulation of the cervical joint to prevent increased intracranial pressure. The patient was not extubated because the brainstem could not be sufficiently reduced coupled with significant autonomic dysfunction.
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