Emergent perioperative care of a patient with Apert’s syndrome, increased intracranial pressure and a difficult airway

Increased intracranial pressure (ICP) is a medical emergency requiring immediate therapy which often includes airway control and endotracheal intubation. Given the need to prevent further increases in ICP, sedation and neuromuscular blockade is frequently used to facilitate endotracheal intubation. However, concerns regarding the ease of endotracheal intubation may complicate the decision process regarding the pharmacologic management of endotracheal intubation. The authors present a 22-year old patient with Apert’s syndrome and increased ICP who required an emergent craniotomy for the treatment of an expanding intracerebral hematoma. Airway management was complicated by a history of a previous difficult intubation. The potential options for anesthetic induction and endotracheal intubation are discussed in the context of competing concerns in this patient with an intracranial mass lesion leading to increased ICP, a history of a difficult airway, and the potential aspiration risk of a full stomach in the emergent setting.