Abstract
Background:
Intracranial epidermoid tumours are rare congenital lesions that grow slowly and often present with neurological symptoms due to compression of adjacent neural structures. The presence of congenital spinal anomalies such as split cord malformation adds complexity to anaesthetic management because of concerns regarding neurological injury, positioning, and maintenance of spinal cord perfusion.
Case Presentation:
We report the case of a 31-year-old female with a known history of split cord malformation diagnosed at the age of 16 years who presented with progressive headache and dizziness. Magnetic resonance imaging of the brain revealed an epidermoid tumour in the cerebellopontine angle. The patient underwent surgical excision of the tumour under general anaesthesia using a remifentanil–rocuronium-based technique. Anaesthesia was induced with remifentanil and propofol, neuromuscular blockade was achieved with rocuronium, and anaesthesia was maintained with sevoflurane, remifentanil infusion, and rocuronium infusion. The intra-operative course remained haemodynamically stable. Neuromuscular blockade was reversed with sugammadex at the end of surgery, allowing rapid emergence and early neurological evaluation.
Conclusion:
Remifentanil–rocuronium-based general anaesthesia provided stable haemodynamics, optimal surgical conditions, and rapid recovery in a patient with split cord malformation undergoing intracranial epidermoid tumour excision. This technique facilitated safe perioperative management and early post-operative neurological assessment.
Keywords:
Epidermoid tumour, Split cord malformation, Remifentanil, Rocuronium infusion, Neurosurgical anaesthesia, Sugammadex
Introduction
Epidermoid tumours are benign congenital intracranial lesions arising from ectodermal inclusions during neural tube closure. They account for approximately 1–2% of all intracranial tumours and most commonly occur in the cerebellopontine angle, parasellar region, and posterior cranial fossa. Due to their slow growth, symptoms often develop gradually and may include headache, cranial nerve deficits, dizziness, or cerebellar dysfunction.
Split cord malformation (SCM), also known as diastematomyelia, is a rare congenital spinal anomaly characterised by longitudinal division of the spinal cord into two hemicords separated by a bony, cartilaginous, or fibrous septum. Patients with SCM may present with neurological deficits, spinal deformities, or remain asymptomatic for many years.
Anaesthetic management in patients with underlying spinal cord anomalies requires careful attention to positioning, haemodynamic stability, and preservation of spinal cord perfusion. In addition, neurosurgical procedures require rapid emergence to allow early neurological assessment.
Short-acting opioids such as remifentanil allow precise titration of analgesia and excellent haemodynamic control, while rocuronium provides reliable neuromuscular blockade and can be
rapidly reversed with sugammadex. These characteristics make the remifentanil–rocuronium combination particularly useful in neurosurgical anaesthesia.
We report the successful anaesthetic management of a patient with split cord malformation undergoing intracranial epidermoid tumour excision using a remifentanil–rocuronium-based anaesthetic technique.
Case Presentation
A 31-year-old female presented with complaints of progressive headache, dizziness, and occasional nausea for several months. She had a known history of split cord malformation diagnosed at the age of 16 years and had been under periodic neurological follow-up. There was no history of prior spinal surgery.
Neurological examination revealed mild weakness of the lower limbs (power 4/5) without sensory deficits or bowel and bladder involvement.
Magnetic resonance imaging of the brain demonstrated a well-defined lesion in the cerebellopontine angle suggestive of an epidermoid tumour, and surgical excision was planned.
During pre-anaesthetic evaluation, the patient was classified as ASA physical status II. Airway examination revealed Mallampati grade II, adequate mouth opening, and normal neck movement. Routine laboratory investigations were within normal limits.
Because of the underlying spinal anomaly, special attention was given to neurological status, spinal alignment, and positioning during surgery.
Anaesthetic Management
Standard monitoring including electrocardiography, non-invasive blood pressure, pulse oximetry, and capnography was established.
The patient was pre-oxygenated with 100% oxygen for three minutes.
Anaesthesia was induced with remifentanil 0.5–1 μg/kg intravenously as a bolus, followed by an infusion of 0.05–0.2 μg/kg/min, along with propofol 1.5–2 mg/kg titrated to loss of consciousness.
Neuromuscular blockade was achieved with rocuronium 0.6 mg/kg to facilitate tracheal intubation. Endotracheal intubation was performed smoothly using a video laryngoscope.
Mechanical ventilation was initiated and adjusted to maintain normocapnia.
Anaesthesia was maintained with an oxygen–air mixture and sevoflurane at a minimum alveolar concentration of 0.8–1.0. Analgesia was continued using remifentanil infusion at 0.05–0.1 μg/kg/min, and neuromuscular blockade was maintained with rocuronium infusion at 5–10 μg/kg/min, titrated using neuromuscular monitoring.
Special care was taken during patient positioning to avoid excessive pressure on the spine and prevent worsening of neurological symptoms related to split cord malformation.
Intra-operative Course
The surgical procedure lasted approximately four hours.
Haemodynamic parameters remained stable throughout the procedure, with no significant fluctuations in heart rate or blood pressure.
Estimated blood loss was approximately 300 mL, which was managed with appropriate intravenous fluid replacement.
No intra-operative complications occurred.
Emergence and Post-operative Course
At the conclusion of surgery, sevoflurane and remifentanil infusions were discontinued.
Neuromuscular blockade was reversed using sugammadex 2 mg/kg after confirmation of moderate blockade on neuromuscular monitoring.
The patient regained consciousness rapidly and was extubated awake with intact airway reflexes.
Post-operative neurological examination showed no worsening of the pre-existing neurological deficit. The patient was monitored in the neurosurgical intensive care unit for 24 hours and had an uneventful recovery.
Discussion
The primary goals of anaesthetic management during intracranial tumour surgery include maintenance of adequate cerebral perfusion pressure, prevention of increases in intracranial pressure, haemodynamic stability, and early neurological assessment after surgery.
In patients with split cord malformation, additional considerations include prevention of spinal cord injury, careful positioning, and avoidance of excessive spinal manipulation.
Remifentanil is particularly advantageous in neurosurgical anaesthesia due to its rapid onset, short context-sensitive half-time, and easy titratability, which allow tight control of haemodynamic responses during surgical stimulation. Its rapid elimination also facilitates early emergence and neurological evaluation.
Continuous infusion of rocuronium provides stable and predictable neuromuscular blockade during prolonged procedures. The availability of sugammadex allows rapid and complete reversal of rocuronium-induced neuromuscular blockade, thereby reducing the risk of post-operative residual paralysis and facilitating early extubation.
In the present case, the combination of remifentanil and rocuronium provided excellent surgical conditions, stable haemodynamics, and rapid recovery, which are desirable characteristics in neurosurgical anaesthesia.
Conclusion
Remifentanil–rocuronium-based general anaesthesia provided excellent haemodynamic stability, optimal surgical conditions, and rapid post-operative recovery in a patient with split cord malformation undergoing intracranial epidermoid tumour excision. This technique facilitated safe perioperative management and allowed early neurological assessment.
References
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Dr Chandan
1st Year DnB PG,
Kauvery Hospital, Chennai.[1]
Dr Jamila
Senior Resident,
Kauvery Hospital, Chennai.[1]