Intracranial air on computerized tomography

Orbitopalpebral emphysema in a child after the removal of a giant meningioma: a case report and mini-review

Research question

to describe and investigate the case of an 11-year-old boy with the concomitant pneumocephalus, subcutaneous- and orbitopalpebral emphysema after the removal of a giant meningioma. Furthermore, our aim is to discuss the findings and the pathophysiology in relation to cases found in literature.

Material and methods

We performed a search in PubMed, Cochrane, MEDLINE and Google Scholar by the usage of the words orbital or periorbital, combined with emphysema and neurosurgery. In addition, a manual search was performed from reference lists.

Results

In the absence of a trauma and fracture in the orbit, it is considered extremely rare with the simultaneous presentation of an orbital emphysema and pneumocephalus. The literature search revealed 1101 results, with four cases of the simultaneous presentation of orbital emphysema and pneumocephalus after a neurosurgical procedure. Our case of an orbitopalpebral emphysema and pneumocephalus following the removal of a giant meningioma is unique.

Discussion and conclusion

Orbital emphysema might give rise to orbital compartment syndrome, an ophthalmologic emergency, that untreated can result in blindness. Differentiating orbitopalpebral emphysema from postoperative swelling can be accomplished through palpation, which might reveal crepitations, and via an acute CT scan that highlights the presence of air.Following a neurosurgical procedure, orbital emphysema is an extremely rare phenomenon. Given the rarity of this case, we present informed assumptions and propose a bidirectional migration of air: from intracranial space, to the orbit and subcutaneously to the palpebrae.

Sudden-onset, non-traumatic large volume pneumocephalus following presentation of acute bacterial meningitis

A man in his 30s, with sinonasal undifferentiated carcinoma status post resection 6 years prior, presented with acute onset of fever, headache and altered mentation. The patient was diagnosed with bacteremia and meningitis due to Streptococcus pneumoniae A standard antibiotic and corticosteroid regimen was started. Brain MRI showed an encephalocele abutting the superolateral nasopharynx mucosa. After several days of clinical improvement, the patient's mental status and headache acutely relapsed. A CT head venogram showed a large volume pneumocephalus originating from the region of a surgical defect. Management included external ventricular drain placement followed by right pterional craniotomy with skull base packing. Skull base defects increase the risk of life-threatening conditions such as bacterial meningitis and pneumocephalus. It is crucial for clinicians to be aware of the possibility of cranial surgical defects developing years after surgery.

Clinical Significance of Pneumocephalus in Pediatric Mild Traumatic Brain Injury

OBJECTIVES

Mild traumatic brain injury (mTBI) comprises most (70%-90%) of all pediatric head trauma cases seeking emergency care. Although most mTBI cases have normal initial head computed tomography scan, a considerable portion of the cases have intracranial imaging abnormalities on computed tomography scan. Whereas other intracranial pathological findings have been extensively studied, little is known about the clinical significance of pneumocephalus in pediatric mTBI.

METHODS

We retrospectively identified pediatric mTBI patients with pneumocephalus using the institutional database of a large regional trauma referral center. Outcome measures were defined as clinically important TBI (ciTBI), hospitalization, intensive care unit (ICU) admission, and neurosurgical intervention. Comparisons were made between pneumocephalus and control (isolated linear fracture) groups as well as between isolated (only linear fracture and pneumocephalus) and nonisolated pneumocephalus (pneumocephalus and TBI) groups.

RESULTS

Among 3524 pediatric mTBI cases, 43 cases had pneumocephalus (1.2%). Twenty-one cases (48.8%) had isolated pneumocephalus. The pneumocephalus group had higher rates of ciTBI, hospital admission, ICU admission, and neurosurgery when compared with the isolated linear fracture (control) group. The isolated pneumocephalus group had fewer ciTBI (21.1% vs 70%, P = 0.002), fewer hospitalization (23.8% vs 81.8%, P < 0.001), but similar ICU admission rates (4.8% vs 22.7%, P = 0.089) and length of hospital stay (4.0 ± 2.7 vs 3.6 ± 2.4 days, P = 0.798) in comparison to the nonisolated pneumocephalus group. None of the patients in the isolated group had neurosurgery whereas 2 patients in the nonisolated pneumocephalus group underwent surgery. Multivariable analysis revealed pneumocephalus as an independent predictor of ciTBI and hospital admission, but not ICU admission or neurosurgical intervention.

CONCLUSION

Pneumocephalus is associated with increased rates of hospitalization and ciTBI, but not ICU admission, unfavorable outcome, or neurosurgical intervention in pediatric mTBI. Although usually spontaneously resolving pathology, it may occasionally be linked with complications such as cerebrospinal fluid leakage, meningitis, and tension pneumocephalus. Therefore, careful evaluation, close observation, and early detection of complications may prevent adverse outcomes.

Lumbar puncture as a cause of tension pneumocephalus, pneumorrachis, and sacral meningocele infection leading to death: An extremely rare case report

Although it was first described over 100 years ago, lumbar puncture is still an important diagnostic tool for a variety of infectious and noninfectious neurologic conditions. With the widespread use of this common and relatively safe performed medical procedure, minor and major complications can occur even when standard infection control measures and good techniques are used, including post lumbar puncture headaches, infection, bleeding, cerebral herniation, radicular pain, and even pneumocephalus in extremely rare cases. We describe a previously unreported complication of lumbar puncture performed for the diagnosis of meningitis in a 33-year-old woman with no medical history causing pneumorrachis, tension pneumocephalus, and sacral meningocele infection leading to death. Lumbar puncture is a simple diagnostic procedure with few complications, but if the technique is incorrectly performed, or if it is accompanied by occult congenital malformations such as sacral anterior meningocele in our case, the consequences can be fatal.

Significance of intracranial gas on post-mortem computed tomography in traumatic cases in the context of medico-legal opinions

The detection of intracranial gas (ICG) in people who died due to trauma became possible once postmortem computed tomography (PMCT) became available in addition to traditional post-mortem examinations. The aim of this study was to determine the importance of ICG in the context of medico-legal opinions. We assessed 159 cases of trauma-induced death. Cadavers with pronounced signs of decomposition, open skull fractures, and after neurosurgical operations were excluded. Both PMCT findings and data from autopsy reports were analyzed. ICG was found in 38.99% (n = 62) of the cadavers, 96.77% (n = 60) of which presented with pneumocephalus (PNC) and 40.23% (n = 25) with intravascular gas (IVG). There was a strong correlation between ICG and skull fractures/brain injuries, as well as chest injuries, especially lung injuries. In 13 cases, ICG presented without skull fractures; three of these cases died as a result of stab and incised wounds to the neck and chest. The mean time between trauma and death was significantly longer in the non-ICG group than the ICG group at 2.94 days (0–48 days) and 0.01 day (0–1 day), respectively (p < 0.0001). The presence of ICG is a result of severe neck and chest injuries, including stab and incised wounds. The victims die in a very short amount of time after suffering trauma resulting in ICG. The ability to demonstrate ICG on PMCT scans can be of significance in forming medico-legal opinions.

Effective but uncommon treatment of a spontaneous otogenic epidural pneumocephalus

We describe an uncommon treatment for epidural pneumocephalus and an effective but uncommon treatment option. Complete and permanent relief was achieved in a young patient using a tympanostomy tube to eliminate excessive positive air pressure in the mastoid bone that was the cause of spontaneous pneumocephalus. The patient showed no recurrence and absence of clinical symptoms at outpatient follow-up. Post-traumatic, infectious or spontaneous pneumocephalus may require an active, usually surgical approach. Treatment with a tympanostomy tube can be an alternative in suitable patients.

Acute Outcomes of Isolated Pneumocephali in Children After Minor Blunt Head Trauma

OBJECTIVES

We aimed to determine the prevalence of and adverse outcomes caused by pneumocephali in children with minor blunt head trauma who had no other intracranial injuries (ie, isolated pneumocephali).

METHODS

We conducted a secondary analysis of a public use dataset from a multicenter prospective study of pediatric minor head trauma. We included children younger than 18 years with Glasgow Coma Scale (GCS) scores of 14 or 15 and non-trivial mechanisms of injury who had cranial computed tomographies obtained. Patients with isolated pneumocephali were those without other traumatic brain injuries (TBIs) but could have non-depressed or basilar skull fractures (BSFs). We defined adverse outcomes as death, need for neurosurgery, or intubation more than 24 hours for TBI.

RESULTS

Pneumocephali occurred in 148 (1.0%; 95% confidence interval, 0.8%-1.2%) of 14,983 patients; 54 (36.5%) of 148 were isolated. Of these 54 patients, 42 (77.8%) had associated BSFs (7 of whom also had linear skull fractures) and 8 (14.8%) had associated linear skull fractures without BSFs; 4 patients (7.4%) had no fractures. Thirty-three patients (61.1%) had both GCS scores of 15 and no other signs of altered mental status. All patients with isolated pneumocephali and available descriptive data (n = 26) had small-sized pneumocephali. There were no deaths, neurosurgical interventions, or intubations for more than 24 hours for TBI (95% confidence interval for any of the outcomes, 0%-7.9%) in the 54 patients with isolated pneumocephali.

CONCLUSIONS

Children with isolated pneumocephali and GCS scores of 14 or 15 after minor blunt head trauma are unlikely to have adverse clinical outcomes.

Bi-frontal pneumocephalus is an independent risk factor for early postoperative agitation in adult patients admitted to intensive care unit after elective craniotomy for brain tumor: A prospective cohort study

Postoperative agitation frequently occurs after general anesthesia and may be associated with serious consequences. However, studies in neurosurgical patients have been inadequate. We aimed to investigate the incidence and risk factors for early postoperative agitation in patients after craniotomy, specifically focusing on the association between postoperative pneumocephalus and agitation. Adult intensive care unit admitted patients after elective craniotomy under general anesthesia were consecutively enrolled. Patients were assessed using the Sedation-Agitation Scale during the first 24 hours after operation. The patients were divided into two groups based on their maximal Sedation-Agitation Scale: the agitation (Sedation-Agitation Scale ≥ 5) and non-agitation groups (Sedation-Agitation Scale ≤ 4). Preoperative baseline data, intraoperative and intensive care unit admission data were recorded and analyzed. Each patient's computed tomography scan obtained within six hours after operation was retrospectively reviewed. Modified Rankin Scale and hospital length of stay after the surgery were also collected. Of the 400 enrolled patients, agitation occurred in 13.0% (95% confidential interval: 9.7-16.3%). Body mass index, total intravenous anesthesia, intraoperative fluid intake, intraoperative bleeding and transfusion, consciousness after operation, endotracheal intubation kept at intensive care unit admission and mechanical ventilation, hyperglycemia without a history of diabetes, self-reported pain and postoperative bi-frontal pneumocephalus were used to build a multivariable model. Bi-frontal pneumocephalus and delayed extubation after the operation were identified as independent risk factors for postoperative agitation. After adjustment for confounding, postoperative agitation was independently associated with worse neurologic outcome (odd ratio: 5.4, 95% confidential interval: 1.1-28.9, P = 0.048). Our results showed that early postoperative agitation was prevalent among post-craniotomy patients and was associated with adverse outcomes. Improvements in clinical strategies relevant to bi-frontal pneumocephalus should be considered.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02318199).

Tension pneumocephalus secondary to non-invasive mechanical ventilation in a patient with severe traumatic brain injury

The presence of air inside intracranial cavity is a rare entity known as pneumocephalus and in most cases doesńt present any clinical repercussion except in case of elevated intracranial pressure that can lead to a decreasing level of consciousness, coma and even death. We present a rare case of a young male, without medical precedents of interest, hospitalized in an intensive care unit for vigilance after a traffic accident with asymptomatic crane encephalic trauma and cranial computerized tomography without meaningful findings. During the intensive care unit stay positive pressure is applied in airway with non-invasive mechanical ventilation that produces air entrance in cranial cavity (pneumocephalus) causing neurological deterioration and necessity of urgent surgery.

Intraventricular pneumocephalus associated with nasocephalic necrosis in a puppy: a case report

ABSTRACT Pneumocephalus is defined as the presence of air in any of the intracranial compartments. Its most frequent causes are trauma and cranial surgery. Clinical signs occur as a result of increased intracranial pressure and vary with the location and extent of the lesion. A case involving a seven-month-old female Saint Bernard, who suffered cranial trauma caused by a bite to the face at ten days of age and had presented with seizures and localized pain four months previously is reported. A computed tomography scan of the skull revealed a nasocephalic mass with low contrast enhancement, bone lysis, and hypodensity (-940 Hounsfield units) of the lateral and third ventricles, indicating intraventricular pneumocephalus. During surgery, a fragment of the mass was collected for histopathological examination, which demonstrated the presence of multifocal areas of necrosis. The computed tomography (CT) is a reliable method for the characterization of intracranial lesions and diagnosis of pneumocephalus, whose occurrence must be considered in pathological processes in which there is increased intracranial pressure and in patients undergoing certain surgical procedures and anesthetic specific, and CT is indicated as a monitoring tool for these patients.

Giant Spontaneous Epidural Pneumatocele: Case Report and Review of the Literature

BACKGROUND

Pneumocephalus is a commonly encountered finding in neurosurgery in which air displaces intracranial cerebrospinal fluid after cranial surgery or a cerebrospinal fluid leak into paranasal or mastoid sinuses. When an intracranial air collection becomes chronically established in a fixed loculation causing mass effect, pneumatocele is a more appropriate term. We present an unusual case of a spontaneous giant frontotemporal epidural pneumatocele that persisted for more than 1 year before the patient presented for neurological treatment.

CASE DESCRIPTION

A 40-year-old man with a remote history of minor head trauma presented with symptoms of headaches, dizziness, and vertigo. Imaging revealed a right giant epidural pneumocephalus secondary to bony dehiscence of the intracranial wall of the mastoid bone. A subtemporal middle fossa approach was performed to repair the mastoid defect with hydroxyapatite, fat graft, and temporalis fascia. The patient was discharged on postoperative day 2 with improvement in his headaches. One month after discharge operative imaging demonstrated complete resolution of his epidural pneumatocele and improvement in his headaches.

CONCLUSIONS

This unique case represents the first reported case in the neurosurgical literature of a giant spontaneous epidural pneumatocele occurring in an adult treated with a middle fossa approach with resolution on follow-up imaging.

Post-traumatic epidural tension pneumocephalus: a case report

Introduction

Pneumocephalus is usually a self-limiting condition commonly associated with neurosurgical interventions, head and facial trauma. In contrast, tension pneumocephalus is extremely rare, and considered a neurosurgical emergency.

Case presentation

We present a rare case of post-traumatic epidural tension pneumocephalus in a 30-year-old white man who deteriorated rapidly after a blunt head trauma. Imaging revealed a large, right temporoparietal epidural pneumocephalus with mass effect, most likely arising from a small defect in the mastoid sinus. A pre-existing mucocele was also suspected. Emergency burr hole evacuation was performed and he experienced full recovery, but more invasive treatment was eventually needed to resolve the condition.

Conclusions

Epidural tension pneumocephalus is a rare and potentially life-threatening condition, but treatable with the right management. To the best of our knowledge, a post-traumatic tension pneumocephalus caused by a pre-existing mucocele has not been reported in the literature.

Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

OBJECTIVES

Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS.

METHODS

The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1-10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0-4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak.

RESULTS

The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed "suspicious" pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as "benign" pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0-4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of "suspicious" pneumocephalus provides the best overall prediction for postoperative CSF leaks.

CONCLUSIONS

Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A "suspicious" pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of "suspicious" pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.

Delayed spontaneous pneumocephalus in ventriculoperitoneal shunting: two case reports and literature review

Spontaneous pneumocephalus following cerebrospinal fluid shunt is a rare complication. In most cases, the air enters in the intracranial cavity via a skull base defect. We report 2 cases of delayed tension pneumocephalus, secondary to ventriculoperitoneal shunt, and review the etiopathogenesis, prevention and treatment of this condition.

Tension pneumocephalus: a case report with review of literature

Tension Pneumocephalus (PC) was described 50 years ago. A case of pneumocephalus (PC) following cervical epidural injection in a 50-year-old male worsened by air travel and manifested as tension pneumocephalus, confirmed by advanced neuroimaging, is reported for the first time along with literature review. The patient underwent emergent frontal burr hole evacuation and air gushed under pressure. The patient recovered well and is stable during a follow-up of 12 months. Presenting features and clinical course along with Mount Fuji sign, Peaking sign, and air bubble sign observed in this case are described. Also, the importance of considering neurosurgical and spinal procedures leading to PC have to be considered by practitioners before issuing fitness certificate before air travel, as PC is likely to get transformed to tension PC and can cause an in-flight emergency.

Spontaneous pneumocephalus caused by pneumococcal meningitis

Pneumocephalus is a condition characterized by the presence of air in the cranium, and it is mainly caused by trauma or a neurosurgical procedure. In the absence of head trauma or a neurosurgical procedure, meningitis is an extremely rare cause of pneumocephalus. Here, the authors present a rare case of spontaneous pneumocephalus caused by pneumococcal meningitis, in which simple lateral radiography and computed tomography (CT) findings of the skull suggested the diagnosis. Cerebrospinal fluid analysis showed bacterial meningitis which later revealed streptococcus pneumonia. The patient was treated with antibiotics and responded remarkably well. Repeat CT performed after 2 weeks of treatment showed complete resolution of the intracranial gas. Here, the authors report an unusual case of a pneumocephalus caused by meningitis in the absence of head trauma or a neurosurgical procedure.

Lessons in the management of post-operative tension pneumocephalus complicating transcranial resection of advanced cutaneous tumours with free flap reconstruction

Tension pneumocephalus is a rare, but potentially life-threatening complication of transcranial surgery. Whilst commonly described in the field of neurosurgery, little has been published in the context of craniofacial surgery. We describe two cases of post-operative extradural tension pneumocephalus occurring following free myocutaneous latissimus dorsi flap reconstruction of anterior cranial defects following extirpation of advanced recurrent skin carcinomas. These cases illustrate the variation in clinical presentation of this condition, the importance of prompt recognition, urgent radiological investigation and timely decompression, and potential management strategies for minimising the risk of recurrent symptoms.

Spontaneous intraparenchymal otogenic pneumocephalus: A case report and review of literature

Background:

Pneumocephalus is commonly associated with head and facial trauma, ear infection, or surgical interventions. Spontaneous pneumocephalus caused by a primary defect at the temporal bone level without association with pathological conditions is very rare. Few cases have been published with purely intraparenchymal involvement. We describe a rare case of spontaneous pneumocephalus arising from the mastoid cells with intraparenchymal location and present an extensive review of the existing literature.

Case Description:

A 57-year-old woman presented a brief episode of sudden otalgia in her left ear that was followed by a motor aphasia. Imaging revealed a left temporal intraparenchymal pneumocephalus in a close relationship with a highly pneumatized temporal bone. Left temporal craniotomy and decompression were performed. Further subtemporal exploration confirmed a dural defect and other osseous defects in the tegmen tympani, which were both consequently closed watertight.

Conclusion:

Although extremely rare, a spontaneous intraparenchymal pneumocephalus with mastoidal origin should be considered as a possible diagnosis in patients with suggestive otological symptoms and other non-specific neurological manifestations. Surgery is indicated to repair bone and dural defects.

Postmastoidectomy pneumocephalus: case report

Chronic otitis media, unlike trauma, seldom leads to the development of tension pneumocephalus. Rarely, it occurs as a complication of mastoid surgery. A Melanesian woman sought treatment for loss of speech, hemiparesis, and headache 4 weeks after undergoing canal-down mastoidectomy for cholesteatoma. The tension pneumocephalus was decompressed urgently by aspirating air via a cannula through the burr hole, and the mastoid cavity was obliterated. She recovered completely. Twelve additional patients with postmastoidectomy pneumocephalus reported in the literature are reviewed.

Spontaneous otogenic pneumocephalus presenting with occipital subcutaneous emphysema as primary symptom: could tension gas cause the destruction of cranial bones?

The authors report, to the best of their knowledge, the first case of a spontaneous tension pneumocephalus with subcutaneous emphysema. Hyperpneumatization of the cranium and mechanical compression contributed jointly to the formation of a fistula, and air pressure caused a subsequent disruption of the suture and air leakage into the subcutaneous space. A minimally invasive otological procedure proved efficacious for resolution.

Spontaneous otogenic pneumocephalus

The diagnosis and management of spontaneous otogenic pneumocephalus with literature review is described. A young sportsman experienced headache and fluctuating mass in his occiput during increased physical activity. A large extradural intracranial pneumocephalus with corresponding emphysema was imaged on a CT scan. Transmastoid identification and plugging of temporal bone defect solved the problem with complete pneumocephalus and emphysema resorption.

Diffuse pneumocephalus : a rare complication of spinal surgery

The common etiologies of pneumocephalus, presence of air in the intracranial cavity, are trauma and cranial surgery. Pneumocephalus after spinal surgery is an unusual postoperative complication. We report the case of a male 59-year-old man who developed a pneumacephalus after posterior lumbar surgery for spinal stenosis. Intraoperatively, a cerebrospinal fluid leak following a dural tear was noted and immediately repaired. The next day, the patient complained of headache and dizziness. Head and lumbar computed tomography scans revealed significant air in the frontal region, several cisterns, intraventricle, and extra-dural area in the spine canal. Symptoms were spontaneously resolved within 2 weeks with conservative management.

Pneumocephalus as a complication of diverticulitis

We report a case of pneumocephalus, as a complication of diverticulitis, in a 48-year-old man who presented with back pain and mild disorientation. There are no previous reports of diverticulitis causing this phenomenon.

Otogenic Tension Pneumocephalus Caused by Therapeutic Lumbar Csf Drainage for Post-Traumatic Hydrocephalus: A Case Report

Tension pneumocephalus occurs when a continuous flow of air accumulates in the intracranial cavity and produces a mass effect on the brain. We describe a case in which tension pneumocephalus was caused by the performance of continuous lumbar CSF drainage in a middle-aged man who had experienced a temporal bone fracture. Continuous lumbar CSF drainage is commonly performed in patients with temporal bone or basilar skull fractures to treat concomitant post-traumatic CSF rhinorrhea, CSF otorrhea, and/or hydrocephalus. However, to the best of our knowledge, there has been no previously reported case of tension pneumocephalus occurring as a complication of this procedure in a patient with a temporal bone fracture.

Tension pneumocephalus--a rare complication of radiotherapy: a case report

We present a rare case of tension pneumocephalus due to high-dose radiotherapy used to treat nasopharyngeal carcinoma. A skull base defect causing tension pneumocephalus was identified and was repaired successfully. The case emphasizes the importance of careful consideration before applying irradiation treatment to patients with head and neck malignancy and urges early detection of potentially life-threatening complications.

Traumatic frontal bone fracture resulting in intracerebral pneumocephalus

Gas within the brain parenchyma, known as intracerebral pneumocephalus, has been infrequently reported. Head trauma is the most common cause. A case of intracerebral pneumocephalus resulting from a golf club injury and a review of the literature are presented.

Intracerebral pneumatocele presenting after air travel

In this report the authors discuss a patient who experienced symptoms of an acute right frontal, intraparenchymal pneumatocele while on an airplane descending to an international airport. This rare complication of an ethmoid sinus osteoma that eroded upward through the dura mater is described along with a literature review. A persistent headache and inappropriate behavior consistent with a frontal lobe syndrome brought the patient to clinical and imaging evaluation, which revealed a large right frontal lobe pneumatocele and an associated ethmoid sinus osteoma extending upward into the frontal lobe. Through a right frontal craniotomy, the air cavity was evacuated, the osteoma partially excised, and the dural defect closed using a vascularized pericranial flap. Postoperatively, the patient made an unremarkable recovery. For patients with air sinus osteomas extending into the cranial cavity, air travel or other barotrauma may result in a life-threatening tension pneumatocele.

Management of intracranial complications of sinus surgery

Endoscopic sinus surgery has an impressive and continually im-proving safety record. Increasing surgical experience and improved techniques and equipment make this procedure fundamentally safe. Anatomic variations, extensive disease, and the tight confines that the sinuses occupy between the skull base and orbits, however, do allow the possibility of untoward events. Many of these complications are minor, but the potential for significant morbidity, including blindness, diplopia, cerebrospinal fluid fistula with or without meningitis, intracranial brain injury, and hemorrhage from internal carotid artery injury, is real. This article discusses the avoidance and management of these complications.

Anesthetic technique and development of pneumocephalus after posterior fossa surgery in the sitting position

OBJECTIVE

Pneumocephalus is a well-known complication of surgical procedures performed with the patients placed in the sitting position. Its incidence and intensity were prospectively studied in 90 consecutive patients undergoing a posterior fossa procedure in this position. Various anesthetic agents, with different effects on cerebral hemodynamics, were used.

MATERIAL AND METHODS

Patients were randomly assigned to one of three groups. In group 1 (n=30), anesthesia was induced and maintained with propofol. In group 2 (n=30), anesthesia was induced with thiopental and maintained with isoflurane. In group 3 (n=30), anesthesia was induced with thiopental and maintained with nitrous oxide and low-dose isoflurane. All patients received a load dose and an infusion of fentanyl. A cerebral computed tomography scan was performed to all patients 8 hours after surgery for detecting the presence and location of intracranial air. The size of pneumocephalus was ascertained using the formula for calculating the volume of a spheroid: v = PI / 6. x. y. z. Preoperative diagnosis, existence of shunted or non-shunted hydrocephalus, type and duration of the surgical procedure, detection of intraoperative venous air embolism, and appearance of new neurological symptoms in the postoperative period, were recorded.

RESULTS

All patients included in the study developed postoperative pneumocephalus. There were no significant differences (P = 0.133) in the estimated volume of intracranial air between the groups (group 1, volume = 38.3 -/+ 35.4 ml; group 2, volume = 48.9 -/+ 36.3 ml; group 3, volume = 31.5 -/+ 28.4 ml). Only two patients in the group 2 manifested symptoms of neurological involvement due to the pressure exerted by the intracranial air.

CONCLUSIONS

Despite the hypothetical diverse effects of the three anesthetic techniques used in this series on cerebral hemodynamics, our results suggest that none of them has a substantial effect on the amount of intracranial air detected after posterior fossa procedures performed in seated individuals. To the best of our knowledge this is the first report that addresses in a prospective manner the effects of several habitual anesthetic techniques on the development of pneumocephalus in patients submitted to posterior fossa procedures performed in the sitting position.

Pathology of head trauma

This article reviews the essential primary and secondary injuries attributable to traumatic brain injury (TBI) which causes one third of all injury deaths in the United States. Motor vehicle crashes, falls, assaults, guns, sports, and recreational activities are the major causes of TBI. Secondary peak incidences of TBI occur in infants and children and the elderly. Conditions that increase risk for accidents include alcoholism, prior head injury, prior meningitis, seizure disorders, mental retardation, and psychiatric disorders. However, gunshot wounds to the head are steadily increasing and since 1990 have caused more deaths each year than motor vehicle accidents. The incidence, severity, etiology, and specific types of injuries have been assessed in clinicopathologic studies of head injuries. The pathologic features of both the primary and secondary lesions attributed to TBI should be understood by anyone caring for head-injured patients. The computed tomography (CT) and magnetic resonance (MR) images mirror the pathologic abnormalities found in head trauma. Radiologists must accurately interpret the CT and MR images of injured patients. Forensic pathologists have long appreciated the characteristic focal lesions, such as coup and contracoup contusions, that occur in falls or vehicle accidents, but the understanding of diffuse injuries has been more elusive. Understanding the nature of the focal and diffuse injuries is critical to understanding the morbidity and mortality of brain injury.

Intraparenchymal tension pneumatocele complicating frontal sinus osteoma: case report

OBJECTIVE AND IMPORTANCE

A relatively rare condition of intraparenchymal tension pneumatocele secondary to a frontal sinus osteoma eroding posteriorly and breaching dura mater is described. The scanty body of literature on this subject is briefly summarized, and the importance of this condition as a result of its life-threatening but readily treatable intracranial mass effect is outlined.

CLINICAL PRESENTATION

The patient presented with acute deterioration in conscious state and lateralizing signs from the mass effect of gas under tension. Two weeks earlier, he had experienced vague and subtle changes in personality noticeable only to his family.

INTERVENTION

The patient was cured by a frontal craniotomy, partial excision of the osteoma, and suture repair of the dural defect after evacuation of the pressurized air cavity.

CONCLUSION

This rare condition should be urgently treated in the event of acute deterioration. To prevent a life-threatening situation from arising, elective surgery should be considered for patients known to have air sinus osteomas that are at risk of erosion into the cranial cavity.

Localising the source of pneumocephalus: a diagnostic problem

Temporal bone fractures are a common site of origin for pneumocephalus in the trauma setting, but due to the variegated appearance of the skull base, these are not always evident on conventional scanning techniques. We present a case that illustrates this diagnostic difficulty along with the principles of treating pneumocephalus with Ventriculoperitoneal (VP) shunt in situ.

Iatrogenic pneumocephalus secondary to intravenous catheterization. Case report

The presence of pneumocephalus in a patient without a history of undergoing intracranial or intrathecal procedures is a significant radiographic finding that portends a violation of the dural barrier or the presence of infection. The authors report a case of iatrogenic pneumocephalus that confounded the evaluation of a patient with unrelated neurological disorders, resulting in unnecessary transfer of the patient and utilization of medical resources. A review of 100 sequential computerized tomography scans obtained in patients for any indication in the emergency department revealed a 6% incidence of iatrogenic intravenous pneumocephalus. Computerized tomography scans revealing pneumocephalus had been obtained for altered mental status, focal motor deficit, seizure, and trauma. More careful intravenous catheterization and recognition of the condition on imaging may avoid similar problems.

An unusual fatal complication of low basilar trunk aneurysm surgery: isolated prepontine tension pneumocephalus

OBJECTIVE

A case of postoperative tension pneumocephalus after low basilar trunk aneurysm clipping is presented. To our knowledge, this is the first case of isolated prepontine tension pneumocephalus.

BACKGROUND

A 63-year-old woman was admitted for repair of a basilar aneurysm that had caused a subarachnoid hemorrhage. She was cooperative and partially oriented. According to Hunt & Hess classification, she was considered Grade III.

METHOD

The aneurysm was clipped, using a right lateral suboccipital craniectomy with the patient in the sitting position. In the early postoperative period, she had no new neurological deficit. However, 2 hours later the patient became lethargic and unresponsive to verbal commands. Emergency CT scan revealed an isolated prepontine tension pneumocephalus with prominent posterior displacement of the pons. She was immediately taken back to surgery. Upon incision of the dura mater, air could be heard escaping under pressure from the posterior fossa cavity. The clip was in its proper position and all arteries were patent. Spontaneous respiration and pupil reflexes returned soon after surgery, but she remained unconscious and died 3 days later.

CONCLUSION

We believe that this death was directly attributable to the tension pneumocephalus and the distortion of the pons. Postoperative prepontine tension pneumocephalus, although this is an extremely rare condition, should be considered if a patient deteriorates after basilar aneurysm surgery in the sitting position.

An unusual case of otogenic pneumocephalus

Otogenic pneumocephalus is a rare entity usually caused by temporal bone trauma. This paper describes a case of otogenic pneumocephalus of traumatic origin, in which the type of the fracture (a bony spicula was detached from the mastoid) and the location (Trautmann's triangle) were uncommon.

Pneumocephalus due to nasopharyngeal carcinoma: case report

A 55-year-old man with recurrent nasopharyngeal carcinoma presented with intractable headaches and intermittent rhinorrhoea for 2 weeks. CT showed severe destruction of the skull base by the tumour. The headache persisted despite intraventricular morphine. On the 29th hospital day, sudden onset of neurological deterioration led to coma, and CT revealed tension pneumocephalus due to nasopharyngeal carcinoma breaking through the skull base. The literature on pneumocephalus is reviewed and the aetiology discussed.

An unusual cause of altered mental status

A case of altered mental status secondary to pneumocephalus as a complication of sinus surgery is presented. The pathophysiology, clinical presentation, diagnosis, and management of pneumocephalus are discussed.

Tension pneumocephalus after transsphenoidal surgery: two case reports

In this paper, a brief information on factors taking role in intracranial air formation and tension pneumocephalus because of two cases epidural air formation and tension pneumocephalus following transsphenoidal operation is presented. Two cases were treated conservatively.

Tension pneumocephalus: treatment with controlled decompression via a closed water-seal drainage system. Case report

The successful treatment of a patient with tension pneumocephalus by controlled decompression via external drainage is described. The advantage of the technique includes the immediate release of high pressure and the capability of maintaining constant low pressure to enable and facilitate sealing of dural tears. The method has been used in three other patients, leading to resolution of the tension pneumocephalus without recurrence or other complications.