An interesting case of interparietal encephalocele.

Dear Sir,

A 15-day-old male child, 2nd sibling of his parents, delivered vaginally in his own home was admitted to neurosurgery department for an ulcerated big swelling on his vertex [Figure 1]. The child was 2.5 kg in weight; swelling was cystic, transilluminant [Figure 2], covered by healthy skin except at the fundus, where it was ulcerated. The child was taken up for surgery after routine screening. He was positioned supine after induction of anesthesia. Initially, the cerebro-spinal fluid (CSF) was allowed to drain through a hypodermic fluid for 15 minutes to avoid sudden decompression of grossly dilated ventricular system [Figure 3]. On the lax swelling, longitudinal elliptical skin incision was planned little away from the neck; dura was easily separated avoiding injury to the vessels run longitudinally and close to neck. Small protrusion of brain parenchyma was seen which was not disturbed [Figure 4]. At the end, dura was closed in two layers followed by scalp closure. Rest of the hospital stay was uneventful. Till the end of 6 months there was no need of CSF drainage procedure, but the patient was lost to follow-up afterward.

Figure 1

Encephalocele showing ulcer at the fundus. Its vertical measurement is 13 cm and circumference is 32 cm

Figure 2

Transillumination of the encephalocele showing evidence of CSF and blood vessels

Figure 3

CT scan of the brain shows a grossly dilated ventricular system

Figure 4

Intraoperative photograph showing protruding brain parenchyma into the herniation

Discussion

Several key points are to be addressed during surgery of large encephaloceles of the vertex. Position of the head and swelling should not cause hindrance for airway management nor it should hinder the closure of wound at the end of surgery. CSF from the swelling may be decompressed slowly.[1-3] Major veins should be spared from injury.[2] Follow-up is required, as the patient may need ventriculo-peritoneal shunt if CSF flow is blocked.[2] Cranial reconstruction may be avoided if bony deficit is small, as brain is yet to grow. Overall prognosis is poor[1] and depends on the contents of the sac, operability, hydrocephalus, and other associated malformations.[1-3]