Sensitivity of the Mount Fuji Sign After Evacuation of Chronic Subdural Hematoma in Nonagenarians:

Massive pneumocephalus as a risk factor for recurrence after chronic subdural hematoma surgery: A systematic review and meta-analysis

BACKGROUND

Symptomatic chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition predominantly managed through burr hole drainage. Postoperatively, pneumocephalus frequently manifests in CSDH cases, and in some instances, tension pneumocephalus may evolve into a life-threatening complication. Despite several studies examining the association between pneumocephalus and recurrence, the outcomes have remained inconclusive.

METHODS

An extensive literature review was carried out utilizing PubMed, EmBase, Web of Science (including Medline), and the Cochrane Library for literature available until September 2024. Studies concerning the association between pneumocephalus and recurrence were identified. Utilizing the PRISMA guidelines, titles, abstracts, and full texts of the selected studies were examined, with articles gradually excluded based on predefined criteria. Data extracted from these studies were processed through RevMan 5.4 software. The primary outcome assessed was hematoma recurrence, while secondary outcomes involved prognosis and mortality rate.

RESULTS

The analysis incorporated nineteen investigations, involving an aggregate of 3,202 individuals with confirmed CSDH diagnoses. The findings indicated that the recurrence rate (RR) in the pneumocephalus group was markedly higher in comparison to the control group (OR, 3.22; 95 % CI, 2.47-4.20, P < 0.00001). The subgroup with extensive pneumocephalus presented a notably higher RR compared to the no/minimal pneumocephalus subgroup (P < 0.00001). Furthermore, the massive pneumocephalus subgroup exhibited a higher RR when contrasted with the no/minimal/moderate pneumocephalus group (P < 0.00001). In addition, the massive pneumocephalus subgroup demonstrated a higher RR compared to the moderate pneumocephalus subgroup (P = 0.003). Nevertheless, no statistically significant variation in RR was identified between the moderate pneumocephalus and no/minimal pneumocephalus groups (P = 0.34). The analysis also demonstrated that outcomes in the pneumocephalus group were poorer when compared with the control group (OR, 0.18; 95 % CI, 0.09-0.35, P < 0.00001). Conversely, no statistically significant difference in mortality rates between the pneumocephalus and control groups (P = 0.67).

CONCLUSIONS

The recurrence of CSDH is linked to the volume of postoperative pneumocephalus. While small or moderate volumes of pneumocephalus do not influence the RR of CSDH, extensive pneumocephalus is considered a marked risk factor for postoperative recurrence in individuals with CSDH. Although pneumocephalus does not appear to affect mortality rates, it has a notable impact on the prognosis of CSDH. These conclusions necessitate further confirmation through large-scale, meticulously designed prospective studies.

Tension pneumocephalus as a complication of surgical evacuation of chronic subdural hematoma: case report and literature review

The management of symptomatic chronic subdural hematoma (CSDH) is surgical evacuation and prognosis in most cases is good. Tension pneumocephalus is the presence of air under pressure in the intracranial cavity. A case of tension pneumocephalus developing as a complication of burr hole evacuation of CSDH is illustrated. In this case, tension pneumocephalus was managed by reopening the wound and saline irrigation with a subdural drain placement. Considering this case report and after a careful review of the literature, the physiopathology, diagnosis, and treatment of this complication are highlighted in the article.

Postoperative pneumocephalus and recurrence and outcome of chronic subdural hematoma: a systematic review and meta-analysis

We conducted a meta-analysis to analyze the effects of pneumocephalus after chronic subdural hematoma (CSDH) surgery on hematoma recurrence, mortality, and functional outcomes. In this meta-analysis, following PRISMA guidelines, PubMed, Embase, Cochrane Library, and Web of Science online databases were queried using the keywords "pneumocephalus," "pneumoencephalos," "intracranial pneumatocele," "pneumo encephalon," "subdural air," and "chronic subdural hematoma." The results were limited to English-language articles. Through the online database, we identified a total of 276 articles and finally included 14 articles for meta-analysis. The results showed that the recurrence rate in the pneumocephalus group was higher than that in the control group, with a pooled OR of 3.35 (CI: 2.51-4.46, P < 0.001). There was no difference in recurrence rate between the no/few and moderate pneumocephalus groups (OR: 1.27, CI: 0.68-2.37, P = 0.46), but the recurrence rate of the large pneumocephalus group was significantly higher than that of the moderate group, with a pooled OR of 3.29 (CI: 1.71-6.32, P < 0.001). This study failed to show higher mortality and worse outcomes in the pneumocephalus group than in the control. Pneumocephalus after surgical evacuation of CSDH was associated with the recurrence rate of hematoma. Pneumocephalus affecting recurrence was correlated with gas volume, and moderate pneumocephalus may have less impact, while patients with large pneumocephalus are more likely to recur than those with moderate pneumocephalus. More prospective cohort studies are needed for further investigation and verification. This meta-analysis was registered (PROSPERO CRD42022321800).

Tension pneumocephalus following an implant removal from spine

Pneumocephalus is commonly seen after skull and maxillofacial fractures. It can also occur following cerebrospinal fluid leak after skull base surgery and epidural catheter placement. We report a rare case report of a 20-year-old man who developed tension pneumocephalus following implant removal from the spine. He responded well to the conservative treatment without any neurological complications.