Meningoencephalocoele

Patient with unilateral hearing loss, rhinorrhoea, and eye discharge. 

Diagnosed with CSF meningoencephalocoele on CT. For craniotomy and resection.

Background

  • Respiratory disease
    • Asbestosis and COPD
    • FEV1 <40%, FVC 70%, DLCO 40%
    • CAP 2021 -> prolonged ventilation in ICU
    • Recurrent pneumothoraces requiring talc pleurodesis 2017. Postoperative delirium/POCD and CO2 retention requiring re-intubation.
    • TTE ’21 – nil cor pulmonale. 
  • HCV + but no viral load. Spontaneously cleared?
  • 4WW, independent with ADLs

Issues

  • Severe respiratory disease
    • Recent antibiotics and steroids 
    • Hyperinflated in clinic, SpO2 92%. Chest clear and expiratory phase normal.
    • BODE 4 (60% mortality at 52mths)
    • Gold class 3B

Discussion

  • What is a skull base meningoencephalocoele?
    • Rare
    • Occur after head trauma (relevant for this man), can be congenital or rarely reported to develop secondary to benign intracranial hypertension. 
    • Trans-sphenoidal, transethmoidal, spheno-orbital, sphenoethmoidal or sphenomaxillary.
    • Commonly present with nasal obstruction, CSF rhinorrhoea, intranasal polyps, recurrent meningitis, and headaches. 
    • Often combined approach, with neurosurgeons and ENT.
    • Treated with endoscopic trans-nasal approach (good access to skull base) or with open surgery.
  • Figure 1

Picture shows transethmoidal meningoencephalocoele

  • Opportunities for optimisation?
    • Recent abx and steroids were in preparation for this surgical episode. Further delay to OT unhelpful.
    • Patient at high risk of postop pulmonary complications and ventilation 
    • Optimised.
  • Alternatives to surgery?
    • No

Plan:

  • ICU 3, assuming nil intraoperative complications
  • Proceed to OT
  • Lung protective ventilation strategies given likely severe bullous disease. 
  • Risk of tension pneumothorax intraoperatively.