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Sreenivasan S, Arora C, Agarwal N, Rallo M, Jaikumar V, Miglani R, Vaishya S, Patir R, Gupta G. Tension Pneumocranium Following Transsphenoidal Surgeries-A Case Report and Systematic Review of Literature with Analysis of Predisposing Factors and Treatment Regimens: Is Early Skull Base Repair Better than Conservative Treatment? World Neurosurg 2023; 176:115-126. [PMID: 37141943 DOI: 10.1016/j.wneu.2023.04.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Conclusive evidence describing the outcomes following different treatment strategies for tension pneumocranium (TP) is lacking. Impact of predisposing conditions like multiple transnasal transsphenoidal (TNTS) procedures, intraoperative cerebrospinal fluid leak, obstructive sleep apnea, continuous positive airway pressure, violent coughing, nose blowing, positive pressure ventilation on TP outcomes is also unknown. METHODS PubMed, Embase, Cochrane, and Google Scholar were searched for articles using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Multivariate logistic regression analysis was done using STATA/ BE ver 17.0. RESULTS Thirty-five studies with 49 cases of endoscopic TNTS surgeries were included. Tension pneumocephalus was seen in 77.5% (n = 38), tension pneumosella in 7 (14.28%), and tension pneumoventricle in 4 (8.16%). Nonfunctional pituitary adenomas (40.81%) were most common lesions associated with TP. The need of mechanical ventilation was significantly higher in patients who received conservative management (odds ratio, 1.34; confidence interval, 0.65-2.74) (P < 0.01). However, incidence of meningitis or mortality were not influenced by factors like age, gender, pathological diagnosis, initial conservative management or early skull base repair, use of adjuvant radiation, intraoperative cerebrospinal fluid leak, multiple TNTS explorations, or presence of precipitating factors. CONCLUSIONS Nonfunctional pituitary adenomas were the most common lesions associated with TP. Multiple TNTS procedures did not increase incidence of meningitis or mortality. Conservative management increased the need for mechanical ventilation but did not worsen the mortality outcomes.
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Affiliation(s)
- Sanjeev Sreenivasan
- Department of Neurosurgery, RUTGERS- Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Chinmay Arora
- Department of Neurosurgery, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Neha Agarwal
- Fetal Centre, Department of Obstetrics & Gynecology, University of Texas health, McGovern Medical School, Houston, Texas, USA
| | - Michael Rallo
- Department of Neurosurgery, RUTGERS- Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Vinay Jaikumar
- Bangalore Medical College & Research Institute, Bangalore, India
| | - Rahul Miglani
- Department of Neurosurgery, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Sandeep Vaishya
- Department of Neurosurgery, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Rana Patir
- Department of Neurosurgery, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Gaurav Gupta
- Department of Neurosurgery, RUTGERS- Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA.
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Li W, Liu Q, Lu H, Wang H, Zhang H, Hu L, Sun X, Gu Y, Li H, Zhao W, Wang D. Tension Pneumocephalus from Endoscopic Endonasal Surgery: A Case Series and Literature Review. Ther Clin Risk Manag 2020; 16:531-538. [PMID: 32606712 PMCID: PMC7311094 DOI: 10.2147/tcrm.s258890] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/07/2020] [Indexed: 12/31/2022] Open
Abstract
Purpose Tension pneumocephalus (TP) caused by endoscopic endonasal surgery is a serious complication. We report four cases of TP caused by endoscopic surgery and review other cases in the literature, with special attention devoted to symptoms, imaging features, and therapeutic approaches. Methods A retrospective chart review of patients who experienced TP caused by endoscopic surgery in our institution between 2015 and 2018 was performed. Additionally, the MEDLINE database was searched for all case series or reports of TP caused by endoscopic surgery. Results Eighteen articles were identified for review, including four cases from the authors’ institution; ultimately, 26 cases were included in the present study. The main symptoms of TP were headache and a change in mental status. Cerebrospinal fluid (CSF) leakage was reported in 21 of the 26 patients (80.8%). Eight of the 26 patients (30.8%) presented with the “Mount Fuji sign” imaging feature. Twenty-four patients were treated with surgical intervention for TP (endoscopic multilayer closure of skull base defect, cranial burr hole, or bifrontal craniotomy). In addition, the present study is the first to report two patients with TP who were successfully treated conservatively. Conclusion The therapeutic method for treating TP should depend on the degree of the mass effect and clinical symptoms. When patients with TP present with obvious symptoms of CSF leakage and intracranial hypertension, urgent surgical multilayer repair of the skull base defects and/or release of the intracranial pressure are keys to treating these patients. However, conservative treatment under close observation is also feasible when the related symptoms are not overtly obvious.
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Affiliation(s)
- Wanpeng Li
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Quan Liu
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Hanyu Lu
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Huan Wang
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Huankang Zhang
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Li Hu
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Xicai Sun
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Yurong Gu
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Houyong Li
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Weidong Zhao
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
| | - Dehui Wang
- Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People's Republic of China
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Tension Pneumoventricle After Endoscopic Transsphenoidal Surgery for Rathke Cleft Cyst. World Neurosurg 2020; 135:228-232. [DOI: 10.1016/j.wneu.2019.12.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/11/2019] [Indexed: 11/21/2022]
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Zlotnik D, Taylor G, Simmoneau A, Viot-Blanc V, Devys JM. Pneumencéphalie après ventilation non invasive en postopératoire de neurochirurgie par voie trans-sphénoïdale : à propos de deux cas. ACTA ACUST UNITED AC 2014; 33:275-8. [DOI: 10.1016/j.annfar.2014.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 03/04/2014] [Indexed: 11/30/2022]
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Campero A, Ajler P, Goldschmidt E, Bendersky D, Campero A. [Tension sellar pneumocele: A case report and review of the literature]. Surg Neurol Int 2012; 3:S395-9. [PMID: 23596554 PMCID: PMC3627815 DOI: 10.4103/2152-7806.104404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 11/06/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Tension pneumocephalus is uncommon after transsphenoidal surgery. There are only few cases reported in the literature in which the air was located at the sellar region exclusively, constituting a sellar pneumocele. In this article, an unusual case of a late onset tension sellar pneumocele is reported. CASE DESCRIPTION A 57-year-old woman consulted because of bitemporal hemianopsia. She had undergone a transnasal surgery for pituitary adenoma and a shunt had been placed because of the presence of cerebrospinal fluid leakage. Furthermore, the patient had undergone a transcranial resection of an intracavernous component of the tumor and radiosurgical treatment had been perfomed too because of its aggressiveness. A magnetic resonance imaging was undertaken and it demonstrated a sellar and suprasellar pneumocele. INTERVENTION A transcilliary approach was performed. The sellar region was enclosed by scarring tissue from her earlier procedures. The scar was opened and the air was evacuated. The sellar floor was subsequently closed with fat and fibrin glue. After the procedure, her visual field returned to normal. One year after her last surgery, she is still asymptomatic. CONCLUSION Sellar and suprasellar tension pneumocele is an extremely rare finding following transsphenoidal surgery. Its clinical manifestation would be visual disturbance due to compression on the optic pathway from below. When diagnosed, tension sellar pneumocele should be evacuated within a short time frame.
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Affiliation(s)
- Alvaro Campero
- Department of Neurosurgery, Hospital Padilla, San Miguel de Tucuman, Argentina
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Lee TJ, Chang PH, Huang CC, Chuang CC. Endoscopic treatment of traumatic basal encephaloceles: a report of 8 cases. J Neurosurg 2008; 108:729-35. [PMID: 18377252 DOI: 10.3171/jns/2008/108/4/0729] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Basal encephaloceles are rare entities that can present as congenital diseases; however, traumatic lesions due to head injuries or iatrogenic causes have been described in the literature. In this study the authors aimed to define placement techniques for free grafts in repairing traumatic basal encephaloceles and to describe the long-term effectiveness of endoscopic treatment.
Methods
Between September 1997 and December 2006, 8 patients with traumatic encephaloceles underwent endoscopic surgery. A free graft following an underlay (2 cribriform plate and 4 ethmoid fovea defects) or obliteration (2 sphenoid defects) procedure was used as the repair material.
Results
All traumatic basal encephaloceles with the associated skull base defects and cerebrospinal fluid (CSF) leakage were successfully treated via the endoscopic approach. There were no major complications or recurrence of meningitis or leakage of CSF encountered after an average follow-up of 77 months.
Conclusions
Long-term follow-up results demonstrated that endoscopic surgery was suitable for the treatment of traumatic basal encephaloceles. The underlay procedure is more appropriate than the overlay procedure in repairing large defects of the anterior skull base. Meticulous manipulations of the endoscope following precise autograft placement are mandatory for the successful repair of traumatic basal encephaloceles.
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Affiliation(s)
| | | | - Chi-Che Huang
- 1Departments of Otolaryngology and
- 2Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
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Chan JW. Suprasellar pneumatocele causing a distal optic nerve and optic chiasmal syndrome. Eur J Neurol 2007; 14:e7-8. [PMID: 17718683 DOI: 10.1111/j.1468-1331.2007.01708.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ruiz-Juretschke F, Mateo-Sierra O, Iza-Vallejo B, Carrillo-Yagüe R. Neumoencéfalo intraventricular a tensión secundario a cirugía transesfenoidal: Presentación de un caso y revisión de la literatura. Neurocirugia (Astur) 2007. [DOI: 10.1016/s1130-1473(07)70300-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yorgason JG, Arthur AS, Orlandi RR, Apfelbaum RI. Endoscopic decompression of tension pneumosella following transsphenoidal pituitary tumor resection. Pituitary 2004; 7:171-177. [PMID: 16010456 DOI: 10.1007/s11102-005-3410-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE AND IMPORTANCE Tension pneumosella is an extremely rare complication of transsphenoidal surgery, having been reported only three times previously. Patients who develop this expanding pneumocele confined to the sella present with visual field changes consistent with optic chiasm compression. If left untreated, this condition can lead to permanent visual deficits. We report a case of tension pneumosella after transsphenoidal resection of a benign pituitary adenoma that was successfully treated endoscopically. CLINICAL PRESENTATION Six months after transsphenoidal resection of a pituitary tumor, a 70-year-old man presented with subjective vision loss and was found on formal testing to have bitemporal hemianopsia. A diagnosis of tension pneumosella was made with a head CT after tumor recurrence was ruled out with MRI. The expanding pneumocele developed after vigorous nose blowing in the setting of a surgical sellar floor defect and an intact diaphragma sellae. INTERVENTION The pneumocele was endoscopically decompressed using a transnasal approach guided by frameless stereotaxy. An immediate decrease in the amount of air was confirmed with intraoperative fluoroscopy. The defect was subsequently repaired with a hemostatic agent and fibrin glue. The patient rapidly recovered his vision and went home on postoperative day one with no further visual complications. CONCLUSION Tension pneumosella should be considered as a possible diagnosis in patients presenting with subacute visual field deficits after transsphenoidal pituitary region surgery. Endoscopy may play a valuable role in the diagnosis and management of this rare phenomenon, as well as other more common complications of transsphenoidal surgery.
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Affiliation(s)
| | - Adam S Arthur
- Department of Neurosurgery and Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Richard R Orlandi
- Department of Neurosurgery and Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ronald I Apfelbaum
- Department of Neurosurgery and Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
- Department of Neurosurgery, University of Utah School of Medicine, 30 North 1900 East, Suite 3B409, Salt Lake City, UT, 84132, USA.
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