Pathogenesis of Delayed Tension Intraventricular Pneumocephalus in Shunted Patient: Possible Role of Nocturnal Positive Pressure Ventilation

Tension pneumocephalus in a patient with NF1 following ventriculoperitoneal shunt-deciphering the cause and proposed management strategy

INTRODUCTION

Spontaneous pneumocephalus following ventriculoperitoneal shunting is a very unique complication, seen in a handful of patients. Small bony defects form as a result of chronically raised intracranial pressure, which can later lead to pneumocephalus once intracranial pressure decreases following ventriculoperitoneal shunting.

CASE REPORT

Here, we present a case of a 15-year-old girl with NF1 who presented to us with pneumocephalus 10 months following shunting and our management strategy along with a literature review of this condition.

CONCLUSION

NF1 & hydrocephalus can lead to skull base erosion, which needs to be looked up before proceeding with VP shunting to avoid delayed onset pneumocephalus. SOKHA with the opening of LT is a minimally invasive approach suitable to tackle both problems simultaneously.

Tension pneumoventricle in a patient with a ventriculoperitoneal shunt and an ethmoidal meningoencephalocele

Background:

Tension pneumoventricle is a rare, life-threatening complication. It has been rarely described in patients with ventriculoperitoneal (VP) shunts.

Case Description:

A 28-year-old male patient with a VP shunt became progressively lethargic after falling from his wheelchair. Skull X-rays and head CT scan showed abundant air inside the ventricles. He was taken to the operating room, and the shunt was revised without improvement. Two days later, a frontal external ventricular drain was placed to remove the air. In the investigation toward the etiology of the pneumoventricle, a review of previous head CT scans and brain MRIs showed that the patient had a small left frontonasal meningoencephalocele extending into the ethmoid, which had been unnoticed. He underwent repair of the defect with adequate sealing of the frontal skull base.

Conclusion:

In a shunted patient with moderate or severe symptoms from a tension pneumoventricle, external ventricular drainage is required to remove the air as the shunt is inadequate.

Tension pneumocephalus following cranioplasty with a titanium plate: a case report

Tension pneumocephalus (TP) can be a life-threatening postoperative complication, but there are limited data owing to its exceedingly low frequency. A 48-year-old man that suffered a head injury survived the acute phase and cranioplasty was performed using a titanium plate. Progressive deterioration of consciousness occurred the day after the cranioplasty. Computed tomography showed the presence of expanded air in the left epidural cavity and a midline shift to the right side. Emergency skin flap reopening was performed. Tension of the scalp decreased when the skin suture was cut and the wound reopened. Lucidity and improved right hemiparesis were obtained within a few hours after drain insertion. Pooled air in the left epidural cavity gradually dissipated postoperatively and the epidural drain was removed 2 days after insertion. The patient was discharged 27 days after cranioplasty, with a modified Rankin scale score of 2. The mechanism that caused TP was considered. Specifically, the skin flap acted as a one-way valve and trapped air. Then the trapped air expanded as the patient’s body temperature warmed. TP should be considered a differential diagnosis after craniotomy. Emergency skin flap reopening and drain insertion may be an effective treatment for TP in the epidural space.

Quadriparesis Due to Delayed Tension Pneumoventricle

INTRODUCTION

Although pneumocephalus is very common after intracranial or spinal surgeries, pneumoventricle is uncommon. Tension pneumoventricle (tPV) occurs when air in the ventricles expands to cause neurological deficits or mass effect. It is usually seen with a combination of a ball-valve defect postoperatively that sucks in air and a ventriculoperitoneal shunt that drains cerebrospinal fluid and allows the ingress of air.

CASE REPORT

A young man developed delayed tPV after surgery for craniopharyngioma. He required multiple surgeries and occlusion of the ventriculoperitoneal shunt before the tPV resolved.

CONCLUSIONS

The probable mechanisms of tPV and the importance of early recognition and treatment are discussed. A review of the literature of this uncommon entity has also been performed.

Tension Pneumoventricle Secondary to Cutaneous-Ventricular Fistula: Case Report and Literature Review

BACKGROUND

Tension pneumoventricle (TPV) is a subtype of tension pneumocephalus in which the air is trapped inside the ventricles through a one-way osteodural defect, causing an increase in intracranial pressure. TPV secondary to cutaneous-ventricular fistula has been reported only twice in the literature.

CASE DESCRIPTION

Herein, we report the third case in a 53-year-old woman who developed TPV with decreased level of consciousness after removal of a posterior fossa meningioma while she was on external ventricular drainage. There was no identifiable bony defect on neuroimaging. The drain was changed urgently, and the fistula located at the drain tunneling site was sealed.

CONCLUSIONS

This case report highlights the importance of suspecting and treating cutaneous-ventricular fistulas in TPV urgently in patients without skull base defects or those who showed no improvements with external ventricular drainage.

Delayed Intraventricular Pneumocephalus Following Shunting for Normal-Pressure Hydrocephalus

BACKGROUND

Pneumocephalus is usually seen in trauma or cranial surgery. It is rarely reported as a delayed complication of ventriculoperitoneal shunt placement for hydrocephalus secondary to trauma, tumor, or aqueduct stenosis. We describe a case of intraventricular pneumocephalus manifesting 10 months after placement of a shunt for normal-pressure hydrocephalus.

CASE DESCRIPTION

A pressure-regulated ventriculoperitoneal shunt was implanted in an 81-year-old patient after diagnosis of normal-pressure hydrocephalus. He showed postoperative clinical improvement. Routine computed tomography performed 2 months after the procedure showed no abnormalities. He presented 10 months after shunting with a subacute deterioration of gait. Imaging revealed major intraventricular pneumocephalus and a left-sided temporal porencephalic cyst with a small, bony defect in the left petrous bone. A middle fossa approach was performed, and the temporal defect was covered with fascia of the temporal muscle. This resulted in a gradual resolution of pneumocephalus.

CONCLUSIONS

Pneumocephalus after shunting for NPH is rare and described as a complication only during the first 2 postoperative months. This case is unique, as the pneumocephalus developed 10 months after shunting. The combination of an occult, possibly congenital, skull base defect and the insertion of a shunt resulted in delayed intraventricular and intraparenchymal pneumocephalus.

Delayed asymptomatic progressive intraventricular pneumocephalus in a dog following craniotomy

Delayed pneumocephalus developed in a 9-year-old dog following transfrontal craniotomy and implantation of an experimental local chemotherapy into a partially resected oligodendroglioma, but the animal appeared to be asymptomatic. MRI evidence of increasing intracranial pressure, including progressive ventricular dilatation and compression of periventricular parenchyma, led to the recommendation for exploratory craniotomy. The barrier between the intracranial cavity and frontal sinus was enhanced, and pneumocephalus resolved on MRI at both 1 and 3 months following the repair.