Pneumocephalus: a rare and life-threatening, but reversible, complication after penetrating lumbar injury

Cognitive dysfunction and decreased level of consciousness due to severe pneumocephalus in granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is a small-vessel vasculitis most commonly affecting the kidneys and respiratory tract. We report a case of a man in his 80s with known GPA presenting with gradually declining cognitive function over months, with sudden decreasing level of consciousness. A non-contrast CT of the head revealed severe pneumocephalus located in the left frontal lobe and in the ventricular system, due to erosion of the cribriform plate and a spontaneous dural perforation. The patient was immediately transferred to a neurosurgical department for insertion of an external ventricular drain. Surgical repair of the dural defect was subsequently performed through an endoscopic, endonasal approach using an autologous fascia lata graft. The patient gradually improved over the following days and had made a complete recovery 3 months after surgery.

Cerebral air embolism associated with cavitary lung lesion in a patient with Ehlers-Danlos syndrome

Pneumocephalus, is a general term describing the presence of air within the intracranial structures. It most commonly occurs due to dural injury, often the sequela of head trauma or surgery. More infrequently, nontraumatic pneumocephalus can be related to infection, Valsalva, fistulization between air-containing organs and intracranial structures, or vascular air embolism. While postsurgical pneumocephalus is often benign, serious consequences of pneumocephalus exist, including tension pneumocephalus and cerebral infarction. We present a case of air embolism and cerebral infarction in a patient with Ehlers-Danlos syndrome, found to have large cavitary lesion in the left upper lobe of the lung, with associated pulmonary vascular malformation seen on bronchoscopy. To our knowledge this is the first reported case of air embolism associated with a pulmonary cavitary lesion and vascular malformation, in a patient with Ehlers-Danlos syndrome.

Fat droplets in the cerebrospinal fluid (CSF) spaces of the brain

It is rare to find free floating fat droplets in the cerebral spinal fluid (CSF) spaces of the brain. When fat droplets are seen in the CSF spaces, the most common cause is the rupture of a dermoid cyst. Dermoid cysts are congenital inclusion cysts that form during the neural tube closure between the third and fifth weeks of embryogenesis. In this case report, we describe a case of a 74-year-old, right-handed female who presented with an acute onset of visual disturbances and left-hand numbness. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head revealed hypodense "lesions" in the lateral ventricles and basal cisterns. The CT Hounsfield unit was between -41 to -83 Hounsfield Units, which is compatible with fat rather than air. The T1 weighted and FLAIR MRI showed hyperintense lesions "floating" on top of the CSF in the lateral ventricles, which is typical for fat droplets, presumably caused by a ruptured dermoid cyst. This case emphasizes the importance of analyzing Hounsfield Units to distinguish lesions by density, where fat ranges from -50 to -150 Hounsfield Units and air is -1000 Hounsfield Units. Pneumocephalus is the presence of air in the epidural, subdural, or subarachnoid space and can cause confusion, nausea, seizures and focal neurological symptoms. A careful analysis of the neuroimaging findings in the CT with or without MRI is important in making a correct diagnosis of a ruptured dermoid cyst versus pneumocephalus.

Pneumocephalus After Lumbar Epidural Steroid Injection: A Rare Complication With Spontaneous Resolution

Pneumocephalus is a rare but potentially serious complication of spinal procedures, characterized by the presence of intracranial air. This report presents the case of a 40-year-old female who developed pneumocephalus following a lumbar epidural steroid injection. She presented to the emergency department with a persistent headache, blurred vision, and eye pain, which began shortly after the procedure. Computed tomography (CT) scans of the head and lumbar spine revealed several air pockets in the cerebellar cisterns and the left frontal horn, as well as in the epidural and paraspinal regions. Despite the presence of intracranial air, the patient's symptoms gradually improved with conservative management, including bed rest, caffeinated drinks, intravenous fluids, and symptomatic relief with butalbital-acetaminophen-caffeine. A repeat CT scan on day four showed a reduction in air pockets, and by day 10, all air pockets had resolved without the need for neurosurgical intervention. The patient's headaches subsided, though she experienced mild residual vision changes. This case emphasizes the importance of recognizing pneumocephalus as a potential complication of epidural steroid injections and highlights the efficacy of conservative treatment. While most cases of simple pneumocephalus resolve spontaneously, careful monitoring is essential to prevent progression to tension pneumocephalus, a life-threatening condition that requires urgent surgical intervention. Further studies are needed to evaluate the risks and outcomes of different techniques used during epidural procedures.

Profound Pneumocephalus and Low-Pressure Hydrocephalus Triggered by Ventriculoperitoneal Shunt Placement after Resection, Fat Graft Reconstruction, and Radiotherapy for a Malignant Skull Base Schwannoma

Background  Tension pneumocephalus is a rare postoperative complication, typically presenting with mental status changes or rapid neurological decline after craniotomy. We report a complex case of tension pneumocephalus triggered by graft retraction after ventriculoperitoneal (VP) shunt placement. Case History  A 39-year-old woman with a recurrent left trigeminal cavernous sinus schwannoma, status post one prior resection, two stereotactic radiosurgery treatments, and one course of fractionated radiotherapy, underwent radical resection with orbital exenteration and abdominal fat free graft reconstruction followed by adjuvant radiotherapy for malignant transformation. She developed subacute ventriculomegaly with altered mental status, prompting VP shunt placement. Three weeks later, she presented with profound pneumocephalus and intraventricular air originating from a large, left-sided sphenoid and maxillary defect, from which the fat graft had retracted. A right frontal external ventricular drain (EVD) was placed, resulting in immediate release of air under high pressure. Definitive treatment required skull base reconstruction with a latissimus dorsi free flap, contralateral nasoseptal flap, antibiotics, and VP shunt revision for treatment of combined cerebrospinal fluid (CSF) leak, pneumocephalus, ventriculitis, and low-pressure hydrocephalus. As of her last follow-up, she was restored to her initial postresection neurological baseline. Conclusion  Tension pneumocephalus is a rare and life-threatening emergency that requires immediate neurosurgical intervention. We report the index case of tension pneumocephalus induced by graft retraction following radiotherapy and CSF diversion. Where observed, tension pneumocephalus resulting from a skull base CSF leak may be associated with low-pressure hydrocephalus, and successful long-term management demands balancing the need for CSF diversion against the integrity of the skull base reconstruction.

Severe pneumocranium after gamma knife stereotactic radiosurgery for brain metastasis: A case report and literature review

RATIONALE

Gamma knife stereotactic radiosurgery (GKRS) is a recognized safe and effective treatment for brain metastasis; however, some complications can present significant clinical challenges. This case report highlights a rare occurrence of cerebrospinal fluid (CSF) leakage and pneumocranium following GKRS, emphasizing the need for awareness and prompt management of these complications.

PATIENT CONCERNS

A 35-year-old male with a history of malignant neoplasm of the lip in 2015 and perineural spread of malignancy into the left cavernous sinus was treated with GKRS in 2017. The patient was admitted emergently 39 days after discharge due to persistent headache and dizziness.

DIAGNOSES

Brain computed tomography (CT) revealed diffuse bilateral pneumocranium alongside an observation of CSF leakage.

INTERVENTIONS

A surgical procedure involving a left frontal-temporal craniotomy was performed to excise a residual skull base tumor and repair the dura, guided by a navigator system. The conclusive pathological assessment revealed the presence of squamous cell carcinoma markers.

OUTCOMES

The patient exhibited excellent tolerance to the entire procedure and experienced a prompt and uneventful recovery process. After surgery, the symptoms alleviated and CSF leak stopped. The follow-up image showed the pneumocranium resolved.

LESSONS

Pneumocranium due to early-stage post-GKRS is uncommon. The rapid tumor shrinkage and timing of brain metastasis spreading through the dura can lead to CSF leak and pneumocranium. We reviewed current treatment options and presented a successful craniotomy-based dura repair case.

Spinal procedures, pneumocephalus, and cranial nerve palsies: A review of the literature

Purpose: Minimally invasive and surgical spine procedures are commonplace with various risks and complications. Cranial nerve palsies, however, are infrequently encountered, particularly after procedures such as lumbar punctures, epidural anesthesia, or intrathecal injections, and are understandably worrisome for clinicians and patients as they may be interpreted as secondary to a sinister etiology. However, a less commonly considered source is a pneumocephalus which may, in rare cases, abut cranial nerves and cause a palsy as a benign and often self-resolving complication. Here, we present the case of a patient who underwent an intrathecal methotrexate infusion for newly diagnosed non-Hodgkin's T-cell lymphoma and subsequently developed an abducens nerve palsy due to pneumocephalus. We highlight the utility of various imaging modalities, treatment options, and review current literature on spinal procedures resulting in cranial nerve palsies attributable to pneumocephalus presenting as malignant etiologies.

Early Mobilization and Rehabilitation to Enhance the Functional Performance of a Hemiparesis Patient Following a Subdural and Subarachnoid Hematoma With Pneumocephalus: A Case Report

A subdural hematoma (SDH) is a medical condition caused by a violent head trauma in which blood accumulates excessively under the dura mater. It occurs when a blood arterial weak point or brain surface aneurysm ruptures and bleeds. The resulting blood accumulation inside and around the skull raises the pressure on the brain. Pneumocephalus, also known as pneumatocele or intracranial aerogel, refers to air in the ventricular cavities or brain parenchyma's epidural, subdural, or subarachnoid spaces. In most cases, neurotrauma is the primary cause of pneumocephalus, mainly when there are skull base fractures. Here, we present a case study of a 65-year-old male patient diagnosed with left hemiplegia following SDH with subarachnoid hematoma (SAH) and pneumocephalus. The severity of the patient's illness, the medical and surgical care provided, the amount of physiotherapy required to aid recovery, the duration of hospitalization, and the discharge location for patients with acute SAH or SDH vary significantly. The patient underwent physiotherapy rehabilitation, and we report that his lower limb strength improved substantially after the therapy. Therefore, physiotherapy is a critical component of treatment to enhance muscle strength, facilitate early and rapid recovery, and manage the clinical manifestations of the condition.

Laparoscopic cholecystectomy induce tension pneumocephalus in a patient with ventriculoperitoneal shunt: A case report and literature review

INTRODUCTION AND PATIENT CONCERNS

We report on a 45-year-old woman who has a ventriculoperitoneal shunt (VPS), experienced drowsy mental status, with hypesthesia and hemiplegia on the left side. Ten days ago she underwent laparoscopic cholecystectomy (LC). Computed tomography revealed tension pneumocephalus, with severe compression on the right side of the brain.

INTERVENTIONS AND DIAGNOSIS

She underwent 2 surgeries, the first surgery was to place a subdural drainage catheter, however, the pneumocephalus relapsed after withdrawing the catheter, and the later surgery was to replace the new VPS.

OUTCOMES

After replacing the VPS, the patient recovers completely after 10 weeks of follow-up.

CONCLUSION

To our knowledge, this is the first report of LC-induced tension pneumocephalus in a patient with VPS. The purpose of this study is to share our experience, with the hypothesized mechanism being the retrograde air through the VPS valve because of high abdominal pressurization. We recommend noting the existence of the VPS when the LC or any abdominal laparoscopy is performed. The VPS should be clamped during any laparoscopic procedure until complete depressurization. Furthermore, all patients with VPS who have neurological deterioration after abdominal laparoscopy should be treated as having the diagnosis of a tension pneumocephalus. These patients need emergency surgery to replace VPS and set the valve for high-pressure, which can result in a quick and complete recovery.

Extensive tension pneumocephalus presented in the setting of a challenging etiology

Background

Pneumocephalus (PNC) is a well-described consequence in postoperative settings and skull fractures that is usually self-limiting. It can get complicated into tension PNC on some rare occasions, leading to an intracranial mass effect. PNC was also reported after unintentional dural puncture throughout the epidural anesthesia process. However, tension PNC resulting from epidural anesthesia procedures is an extremely rare outcome that implies urgent intervention to relieve the tension within the brain. Here, we report a case of an extensive tension intraventricular PNC 2 days following an epidural anesthesia procedure for a femur fixation surgery.

Case Description

A 23-year-old male presented to the emergency department with basal skull fractures and a femur fracture due to a motorcycle accident. His skull base fracture was managed conservatively then he underwent a femur fixation procedure under epidural anesthesia. Two days after, he developed a severe headache with a disturbed level of consciousness. Computed tomography of the brain revealed an extensive PNC that involved all the subarachnoid spaces down to the cervical region and compressing the cerebellum, which was not found in the initial imaging. The patient's status improved after the twist-drill burr-hole evacuation of air under the water seal.

Conclusion

Extensive tension PNC can occur after traumatic brain injury, especially after epidural anesthesia. Such cases should gain high focus because they may differ from simple PNC regarding diagnosis, treatment, and follow-up.

Endoscopic Endonasal Eustachian Tube Obliteration as a Treatment for Tension Pneumocephalus After Translabyrinthine Resection of Vestibular Schwannoma

OBJECTIVE

Cerebrospinal fluid leak and pneumocephalus are rare but potentially devastating complications associated with translabyrinthine resection of cerebellopontine angle masses. Persistent pneumocephalus despite proximal eustachian tube (ET) obliteration is rare. We describe, to our knowledge, the first report of successful management of tension pneumocephalus by endoscopic endonasal ET obliteration using a novel V-loc (Covidien; Medtronic, Minneapolis, MN) suture technique.

PATIENTS

A 63-year-old man presented with altered mental status 10 months after translabyrinthine excision of a left cerebellopontine angle vestibular schwannoma measuring 2.8 × 2.9 × 3.3 cm. Computed tomography demonstrated diffuse ventriculomegaly and new pneumocephalus along the right frontal lobe, lateral ventricles, and third ventricle, and air within the left translabyrinthine resection cavity.

INTERVENTION

The patient underwent left-sided endoscopic endonasal ET obliteration using 2-0, 9-inch V-loc suture.

MAIN OUTCOME MEASURE

Postoperatively, the patient's mental status improved with a decrease in size of the lateral and third ventricles on computed tomography.

CONCLUSION

Endoscopic endonasal ET obliteration, a technique previously applied to recalcitrant cerebrospinal fluid leaks, is a safe and reasonable alternative to reentering the original surgical site for patients with pneumocephalus after lateral skull base surgery. Utilizing a V-loc suture for this technique instead of a traditional suture may improve procedural ease and speed.

Pneumocephalus and headache following craniotomy during the immediate postoperative period

Background

Pneumocephalus may be responsible for post-craniotomy headache but is easily overlooked in the clinical situation. In the present study, the relationship between the amount of intracranial air and post-craniotomy headache was investigated.

Methods

A retrospective observational study was performed on 79 patients who underwent minimal invasive craniotomy for unruptured cerebral aneurysms. Those who had undergone previous neurosurgery, neurological deficit before and after surgery were excluded The amount of air in the cranial cavity was measured using brain computed tomography (CT) taken within 6 h after surgery. To measure the degree of pain due to intracranial air, daily and total analgesic administration amount were used as a pain index. Correlation between intracranial air volume and total consumption of analgesic during hospitalization was tested using Spearman rank correlation coefficients. Receiver operating characteristics (ROC) analysis was used to determine the amount of air associated with increased analgesic consumption over 72 h postoperatively.

Results

The mean amount of intracranial air was 15.6 ± 9.1 mL. Total administration of parenteral and oral analgesics frequency were 6.5 ± 4.5, 13.2 ± 7.9 respectively. A statically significant correlation was observed between daily and total parenteral analgesic consumption after surgery and the amount of intracranial air at followed-up brain CT postoperatively within 24 h (r = 0.69, p < 0.001), within 48 h (r = 0.68, p < 0.001), and total duration after surgery (r = 0.84, p < 0.001). The optimal cut-off value of 12.14 mL of intracranial air predicts the use of parenteral analgesics over 72 h after surgery.

Conclusions

Pneumocephalus may be a causative factor for post-craniotomy pain and headache with surgical injuries.

Pneumocephalus as result of nonsurgical peri-implantitis treatment with an air-polishing device for submucosal debridement-A case report

Background

A subcutaneous emphysema is an infrequent but potentially life‐threatening complication after dental treatment involving instruments functioning with pressurized air. Emphysemata after the use of high‐speed handpieces and air‐syringes are well documented, however, more recently several reports on emphysemata produced by air‐polishing devices during management of peri‐implant biological complications have appeared. To the best of our knowledge, direct development of pneumocephalus after a dental procedure has never been reported before. Introduction of air likely contaminated with oral bacteria to the intracranial space bares the risk of developing meningitis.

Case Presentation

This case report describes the spreading of a subcutaneous emphysema into the intracranial space (i.e., development of a pneumocephalus) after treatment of a peri‐implantitis lesion with an air‐polishing device equipped with the nozzle for submucosal debridement. A subcutaneous emphysema was noticed during the use of an air‐polishing device and the subsequent computed tomography (CT) examination revealed a quite unexpected spreading of the emphysema into the intracranial space. The patient was admitted to the hospital for close surveillance, CT follow‐up, and intravenous antibiotics to prevent the development of meningitis due to the introduction of air—likely contaminated with oral bacteria—into the intracranial space. After 3 days, the patient was discharged in good condition without any further complications.

Conclusion

In case of an extensive subcutaneous emphysema as result of a dental procedure, a more extended radiographic examination including the mediastinal and cranial space should be considered, to assess the risk for potentially life‐threatening complications.

Tension Pneumocephalus From an Eroding Cholesteatoma: A Case Report and Review of the Literature

Pneumocephalus is defined as the presence of air inside the cranial vault. Benign and tension pneumocephalus are different ends of the same disease spectrum. Tension pneumocephalus leads to the formation of a pressure gradient, requiring emergent surgical decompression to prevent herniation of the intracranial structures. In this report, we present a rare case of tension pneumocephalus with essentially benign radiological findings secondary to a ruptured cholesteatoma. The patient was a 64-year-old woman with a history of end-stage renal disease on hemodialysis and hypertension. She presented to the emergency department (ED) with acute-onset weakness and decreased mentation. Physical exam findings were consistent with a cerebrovascular accident (CVA). CT scan and CT angiogram (CTA) were unremarkable for ischemia or hemorrhage but showed signs of free intracranial air, consistent with the diagnosis of pneumocephalus. After the activation of the code stroke, neurosurgery and neurology were consulted. Worsening respiratory status led to a decision to proceed with emergent intubation, but it was held based on the family’s decision to proceed with comfort measures. The patient’s status declined further within minutes and she died. Afterward, the case was discussed with the radiologist, who interpreted the cause as a cholesteatoma that had eroded through the temporal bone.