INTRODUCTION

Meningoencephalocele is a rare but clinically significant neural tube defect characterized by herniation of the meninges and variable amounts of brain tissue through a congenital cranial defect [1]. The global incidence ranges from approximately 0.8 to 4 per 10,000 live births, with a higher prevalence reported in certain regions of Asia [1]. Among its subtypes, giant occipital meningoencephaloceles represent a particularly severe form due to their size, anatomical complexity, and frequent association with intracranial anomalies, such as hydrocephalus, Chiari malformations, and cortical dysplasia [2].

The extent and functional significance of herniated neural tissue are critical determinants of neurological outcomes and long-term prognosis [3]. The primary objectives of surgical management are well established: preservation of viable neural tissue, achievement of watertight dural closure to prevent cerebrospinal fluid (CSF) leakage and infection, and optimization of neurological function [4]. Delayed or inadequate management may lead to life-threatening complications, including progressive neurological deterioration and intracranial infections. In neonates, these objectives must be achieved within the constraints of physiological vulnerability, including limited blood volume, immature thermoregulation, and airway challenges associated with large occipital masses, all of which significantly increase the perioperative risk [5]. Despite advances in neurosurgical techniques, postoperative complications, such as cerebrospinal fluid (CSF) leakage, wound dehiscence, and infection, remain substantial contributors to morbidity and mortality [6]. While neurosurgical principles have been extensively described, the reconstructive challenges of soft-tissue coverage in neonates remain comparatively underreported. Large occipital defects frequently exceed the capacity for primary closure, and neonatal tissues exhibit reduced tensile strength, immature vascularity, and increased susceptibility to ischemia and wound breakdown [7]. Inadequate reconstructive strategies may compromise dural integrity, increase the risk of CSF leakage, and expose neural structures to secondary infections [8]. Emerging evidence suggests that tension-free, well-vascularized flap reconstruction is critical for optimizing surgical outcomes; however, standardized reconstructive approaches for large neonatal cranial defects remain poorly defined [9].

Therefore, this case report presents a multidisciplinary surgical approach that integrates meticulous neurosurgical repair with tailored local flap reconstruction in a neonate with a giant occipital meningoencephalocele. By emphasizing technical decision-making and reconstructive principles, this study aims to provide clinically actionable insights that bridge neurosurgical and reconstructive strategies, with the goal of improving surgical safety and outcomes in this highly vulnerable patient population [10].

METHODS

This study is a single case report describing the multidisciplinary surgical management of a neonate with a giant occipital meningoencephalocele. This report was prepared in accordance with the CARE (CAse REport) guidelines. Written informed consent for the publication of clinical data and images was obtained from the patient’s legal guardians. Institutional approval was obtained, where required. An 11-day-old female neonate with a congenital occipital mass was evaluated at a tertiary care center in India. Comprehensive clinical assessment included a detailed history, physical and neurological examination, and evaluation of systemic stability. Laboratory investigations included complete blood count, serum electrolytes, renal function tests, and assessment of inflammatory markers. Transthoracic echocardiography was performed to exclude any associated congenital cardiac anomalies. Radiological evaluation using computed tomography and/or magnetic resonance imaging was conducted to define the cranial defect, assess the extent of herniated neural tissue, and guide surgical planning, including incision design and reconstructive strategy. A multidisciplinary team consisting of neurosurgery, plastic and reconstructive surgery, anesthesiology, and neonatology developed a staged surgical plan for the patient. The key objectives included the preservation of viable neural tissue, achievement of watertight dural closure, optimization of soft tissue coverage, and minimization of perioperative physiological stress. Special attention was paid to neonatal-specific considerations, including thermoregulation, airway management, fluid balance, and blood loss control. The procedure was performed under general anesthesia with the patient in the prone position using specialized padding to avoid pressure on the sac. Continuous monitoring of the hemodynamic status, temperature, and fluid balance was maintained. A circumferential incision was made at the base of each sac. Nonfunctional herniated neural tissue was excised, whereas viable structures were preserved. Watertight dural closure was achieved using continuous sutures, and duraplasty was performed when necessary to prevent cerebrospinal fluid (CSF) leakage (Figure 1).

Figure 1. Intraoperative Neurosurgical Phase of Meningoencephalocele Excision

Following sac excision, a soft-tissue defect measuring approximately 8 × 6 cm was observed. Primary closure was considered unsafe because of excessive tension. Reconstruction was performed using a local occipital rotation flap elevated in the subgaleal plane, with preservation of the perforator vascular supply. The flap was designed with an approximate 1:1 flap-to-defect width ratio to ensure tension-free coverage (Figure 2).

Figure 2. Occipital Rotation Flap for Tension-Free Reconstruction

The donor site was primarily closed. Layered wound closure was completed using absorbable sutures, and the final skin suture line was positioned away from the dural repair to minimize the risk of CSF leakage. Postoperatively, the patient was monitored in the neonatal intensive care unit (NICU). Standard care included maintenance of thermoregulation, fluid and electrolyte balance, wound monitoring and infection prevention. The clinical outcomes assessed during the early follow-up included wound integrity, flap viability, presence of CSF leakage, signs of infection, and neurological status.

RESULTS

The patient underwent a staged multidisciplinary surgical procedure consisting of neurosurgical excision, followed by reconstructive scalp closure. The total operative time was approximately 180 min. No intraoperative complications, including hemodynamic instability, excessive bleeding, or anesthetic-related events were observed. Following the excision of the meningoencephalocele sac, a soft-tissue defect measuring approximately 8 × 6 cm was identified. Reconstruction using a local occipital rotation flap achieved complete, tension-free coverage of the defect with preserved flap vascularity and satisfactory intraoperative perfusion.

The postoperative course was uneventful. The patient demonstrated stable wound healing, with intact flap viability and no signs of tissue ischemia or necrosis. No cerebrospinal fluid leakage, wound dehiscence, surgical site infection, or neurological deterioration was observed during the early follow-up. The patient remained clinically stable during the early follow-up period with no delayed complications. The reconstructive outcome demonstrated a satisfactory occipital contour and effective protection of the underlying neural structures, as illustrated in the postoperative evaluation (Figure 3).

Figure 3. Postoperative Outcome Following Occipital Flap Reconstruction

Postoperative view demonstrating successful tension-free closure of the occipital defect using a local rotation flap with preserved flap viability, intact wound edges, and no evidence of cerebrospinal fluid leakage, wound dehiscence, or surgical site infection.

Table 1. Summary of Operative Characteristics and Early Clinical Outcomes

DISCUSSION

Reconstruction of giant occipital meningoencephalocele in neonates presents a unique convergence of neurosurgical and reconstructive challenges driven by the biological immaturity and physiological vulnerability of neonatal tissues. Neonatal skin exhibits incomplete structural development, reduced tensile strength, and immature barrier function, rendering it highly susceptible to mechanical stress, ischemia, and wound breakdown [11]. These intrinsic limitations mandate a reconstructive strategy that prioritizes atraumatic handling and strict tension-free closure, particularly in large cranial defects, where primary approximation is frequently inadequate. The wound healing dynamics in neonates further amplify this challenge. Early postoperative tensile strength remains critically low—approximately 3% in the first week and only 30% by three weeks—reflecting delayed collagen maturation and the predominance of type III collagen [12,13]. In this context, closures that rely on tissue elasticity or high-tension approximation are inherently unstable and predisposed to dehiscence. Therefore, flap-based reconstruction, which redistributes mechanical forces and enhances vascularity, is not only advantageous but also biologically essential for maintaining wound integrity and protecting the underlying neural structures.

In addition to local tissue factors, systemic physiology plays a crucial role in the success of reconstruction. Neonates are particularly vulnerable to hypothermia, fluid imbalance, and hypoalbuminemia, all of which impair wound healing and microvascular perfusion [14-16]. Reduced oncotic pressure promotes interstitial edema, compromising flap viability, whereas perioperative stress responses further exacerbate capillary leakage and tissue swelling [17]. These considerations underscore the necessity of minimizing operative time, optimizing thermal control, and ensuring meticulous perioperative management to support the durability of the reconstruction. From a reconstructive standpoint, the principle of tension-free closure is of paramount importance. Excessive tension compromises microcirculation, impairs fibroblast migration, and increases the risk of ischemia and necrosis, particularly in neonatal tissues with fragile vascular networks [18]. In the setting of meningoencephalocele, wound failure carries severe consequences, including cerebrospinal fluid (CSF) leakage, exposure of neural tissue, and an increased risk of central nervous system infection [19]. Accordingly, any closure that demonstrates signs of mechanical strain should be avoided in favor of flap-based techniques. The current literature supports a hierarchy of reconstructive options based on defect size and tissue availability. While primary closure may be feasible for small defects, it becomes unsafe for moderate-to-large defects due to high tension and associated complication rates. Flap-based approaches, including Limberg flaps, V–Y advancement flaps, and keystone-design perforator island flaps (KDPIF), offer superior outcomes by redistributing tension and preserving vascularity [20-22]. Among these, perforator-preserving local flaps are particularly advantageous in neonates because they provide reliable perfusion with shorter operative times and minimal donor site morbidity.

The present case demonstrates that a local occipital rotation flap can achieve effective, tension-free closure in a defect measuring approximately 8 × 6 cm, with preservation of flap viability, and the absence of postoperative complications. This finding aligns with existing evidence that local flaps provide a robust and practical solution for neonatal cranial defects, especially when tissue expansion or free flap reconstruction is not feasible because of time constraints, vessel size, and physiological limitations [23,24]. Another critical factor is nutritional status, particularly serum albumin levels, which significantly influence wound healing outcomes. Hypoalbuminemia is associated with increased edema, impaired collagen synthesis, and higher rates of wound complications and dehiscence [25-27]. Therefore, preoperative assessment and optimization of nutritional status should be considered integral components of reconstructive planning in neonates. The role of a multidisciplinary team (MDT) approach is equally important. Successful outcomes require seamless integration of neurosurgical repair and reconstructive planning, supported by anesthetic and neonatal care optimization. Previous reports have demonstrated that coordinated MDT management reduces complications, such as CSF leakage, infection, and wound failure, while improving overall surgical efficiency and outcomes [28]. Early involvement of reconstructive surgeons in preoperative planning is essential for ensuring appropriate flap selection and operative sequencing. This study has several limitations. As a single-case study, the findings may not be generalizable to all presentations of the meningoencephalocele. In addition, the short follow-up period limited the assessment of long-term neurological and reconstructive outcomes. Furthermore, comparisons were drawn from heterogeneous literature, including myelomeningocele cohorts, which may differ in anatomical and physiological characteristics. Nevertheless, the biological principles and reconstructive strategies discussed remain highly relevant and are supported by consistent trends in the literature.

CONCLUSION

In this case of a neonatal giant occipital meningoencephalocele, a multidisciplinary approach combining watertight neurosurgical repair with tension-free local flap reconstruction achieved safe closure without early complications. These findings highlight that successful outcomes depend on early integration of reconstructive planning, ensuring durable neural protection, and optimizing clinical results in complex neonatal cranial defects.

DECLARATIONS

None

CONSENT FOR PUBLICATION

The Authors agree to the publication in the Journal of Society Medicine.

FUNDING

None

COMPETING INTERESTS

All authors have reviewed and approved the final version of the manuscript and agreed to its publication in the Journal of Society Medicine.

AUTHORS’ CONTRIBUTIONS

R.A. contributed to the conception and design of the study, data acquisition, and manuscript drafting. I.H. contributed to data interpretation, methodological supervision, and critical revision of the manuscript for important intellectual content. S.R. provided clinical expertise, contributed to data validation, and critically reviewed and approved the final manuscript. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

ACKNOWLEDGMENTS

The authors would like to express their sincere appreciation to the Department of Surgery, Faculty of Medicine, Universitas Syiah Kuala/Zainoel Abidin General Hospital, Banda Aceh, Indonesia, for their institutional support and contribution to the successful completion of this study.

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