Epidermoid tumor presenting as tension pneumocephalus. Case report

Tension Pneumocephalus With Acute Cerebellar Symptoms Due to an Intradiploic Epidermoid Cyst Eroding the Mastoid Bone

This case report presents a unique presentation of an intradiploic epidermoid cyst (IDEC) in a 55-year-old female. She presented with acute cerebellar symptoms triggered by a Valsalva maneuver. IDECs are a rare type of intracranial epidermoid cysts. They are benign and have a slow growth pattern that translates into progressively developing symptoms instead of acute symptoms. Symptoms include local deformities, focal neurologic deficits, and pain. This patient developed acute cerebellar symptoms due to erosion of the mastoid bone that created a pathway between the eustachian tube and the intracranial space via the mastoid air cells. Consequently, tension pneumocephalus emerged via a ball-valve effect that caused a significant mass effect in the posterior fossa. Surgical resection of the IDEC and closing of the mastoid air cells resulted in symptom relief by restoring the integrity of the intracranial-extracranial barrier. This case highlights that a higher level of vigilance is warranted for an IDEC in the proximity of aerated bone structures, such as the mastoid air cells and the paranasal sinuses, and that a more proactive approach is advocated.

Delayed Progressive Intraparenchymal Tension Pneumocephalus after Craniotomy for Recurrent Pituitary Macroadenoma: A Case Report

Pneumocephalus is defined as the presence of air in the intracranial cavity. In most cases, its evolution is asymptomatic and benign. Pneumocephalus post-surgery is a frequent complication of cranial surgery. We herein report delayed tension pneumocephalus after craniotomy for pituitary macroadenoma. A 73-year-old man with recurrent pituitary macroadenoma underwent subtotal resection via subfrontal approach. The postoperative course was uneventful and the patients regained his normal daily living activities. Two months after the surgery the patients developed decreased level of consciousness and was diagnosed to suffer from tension pneumocephalus. Another craniotomy was performed and the dural defect at the base was repair with secondary graft and bone wax. The patient improved neurologically and had no pneumocephalus. The follow-up revealed good condition and outcome. In conclusion, tension pneumocephalus can occur at any time after craniotomy and post-surgical deterioration after resection of a giant pituitary tumor should be immediately assessed. There is not enough evidence to correlated tumor size with rates of pneumocephalus in this particular report, but further cases may need to be studied to come to a conclusion.

Tension pneumocephalus secondary to osteoradionecrosis of the clivus

We report the case of a 36 year-old man with relapsing undifferentiated nasopharyngeal carcinoma treated with a re-irradiation Cyberknife, who subsequently developed tension pneumocephalus due to a cerebrospinal fluid leakage located at the clivus. The fistula was caused by osteonecrosis of the skull base secondary to the tumor invasion and to the sequelae of the radiotherapy. An endoscopic endonasal technique was used in order to repair the defect, with a peduncolated nasoseptal flap harvested to perform the skull base reconstruction. In this paper, we discuss the importance of identifying this possible complication related to radiotherapy in the management of neoplasm along the skull base; moreover, the role of endoscopy in the diagnosis and treatment of skull base fistulas is also described and commented.

Pneumocephalus: case illustrations and review

BACKGROUND

Pneumocephalus is commonly encountered after neurosurgical procedures but can also be caused by craniofacial trauma and tumors of the skull base and rarely, can occur spontaneously. Contributing factors for the development of pneumocephalus include head position, duration of surgery, nitrous oxide (N(2)O) anesthesia, hydrocephalus, intraoperative osmotherapy, hyperventilation, spinal anesthesia, barotauma, continuous CSF drainage via lumbar drain, epidural anesthesia, infections, and neoplasms. Clinical presentation includes headaches, nausea and vomiting, seizures, dizziness, and depressed neurological status. In this article, we review the incidence, mechanisms, precipitating factors, diagnosis, and management of pneumocephalus. Search of Medline, databases, and manual review of article bibliographies. Considering four case illustrations that typify pneumocephalus in clinical practice, we discuss the common etiologies, and confirm the diagnosis with neuroimaging and management strategies. Avoidance of contributing factors, high index of suspicion, and confirmation with neuroimaging are important in attenuating mortality and morbidity. A significant amount of pneumocephalus can simulate a space-occupying lesion. Supplemental oxygen increases the rate of absorption of pneumocephalus.

Pneumocephalus after interventional therapy in esophageal cancer

Pneumocephalus has been reported to have many causes. To our knowledge, a case of tension pneumocephalus caused by subarachnoid-esophagus fistula has not been reported previously. In this report, an unusual case of tension pneumocephalus, which appeared after esophageal cancer disrupting paravertebral tissue resulted in subarachnoid-esophagus fistula, is presented and the involvements in tension pneumocephalus are discussed.

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.

Intradiploic epidermoid cysts of the skull: a report of four cases

Epidermoid cysts are uncommon, benign and slow-growing lesions. They may often reach an enormous size without producing neurological symptoms. Intradiploic epidermoid cysts are nearly 25% of all epidermoids. They are derived from ectodermal remnants that stay within the cranial bones during embryonic development. Intradiploic epidermoid cysts can be located in any part of the skull. Two of our four cases were located in left occipital bone and the others were in the frontal bone. These tumours can occur at any age from the first to the seventh decade of life. Our cases had a mean age of 38.75 years (19-55 years). They may reach great sizes before the initial diagnosis and may produce major neurological signs. For good long-term prognosis, correct radiological assessment and complete removal of the tumour with its capsule are essential. We report four cases of intradiploic epidermoid cysts of the skull and analyse the clinical, radiological features and treatment of these lesions in the light of relevant literature.

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.

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.

Tension pneumocephalus related to an epidermoid tumor of ethmoid sinus origin

A 37-year-old man presented with a four-week history of progressive left-sided weakness, frontal headache, confusion, and drowsiness. A computed tomography evaluation of the head revealed a 7-cm pneumatocele in the right frontoparietal region with shift of the falx to the left. The patient was taken to surgery, where the pneumatocele was decompressed and an epidermoid tumor that originated in the left ethmoid sinus was removed. After the operation, the presenting symptoms resolved promptly.

Spontaneous trigemino-pontine pneumocephalus

A case of a spontaneous trigemino-pontine pneumocephalus in a 25-year-old man without any known risk factors is described. Other cases of spontaneous pneumocephalus in the literature are briefly reviewed.

Tension pneumocephalus after CSF shunting procedures

We report a case of tension pneumocephalus following the insertion of a ventriculoperitoneal shunt for hydrocephalus secondary to aqueduct stenosis and discuss the possible genesis of the complication, diagnosis and treatment.

Tension pneumocephalus five years after intracranial resection of pituitary adenoma--a case report

A case of spontaneous pneumocephalus with progression to tension pneumocephalus is presented. It is unique because it occurred spontaneously via a sellar defect 5 years after resection and irradiation of a pituitary adenoma, without tumor recurrence. Computed tomography clarified the extent of the pneumocephalus and its progression to tension pneumocephalus.

Completely reversible, severe, acute neurological deterioration with an otherwise asymptomatic, huge intradiploic calvarial epidermal cyst

A huge, intradiploic, right temporoparietal epidermal cyst was known to be present, unchanged in extent, for over 14 years in a 55-year-old man. Although extreme mass effect was demonstrated by computed tomography scans, results of the neurological examination were within normal limits. Treatment of nausea and vomiting after vestibular testing caused somnolence and an acute diencephalic-mesencephalic syndrome of tentorial herniation. However, only moderate amounts of analgesics and sedatives were given. These symptoms disappeared as the pharmacological sedative effect diminished. Thereafter the tumor was resected radically. Neuropathological examination confirmed an epidermal cyst. Results of the postoperative neurological examination were within normal limits.

Pneumocephalus in patients with CSF shunts

The authors present two cases of pneumocephalus occurring in patients with permanent shunts and review nine previously reported cases. Mental status changes and headache are the most common presenting symptoms. Six of the 11 cases of pneumocephalus occurred in patients with shunt placement for hydrocephalus secondary to aqueductal stenosis. In these patients, thinned cerebrospinal fluid barriers secondary to long-standing increased intracranial pressure may predispose them to pneumocephalus. Temporary extraventricular drainage is an effective method of treatment in this group of patients. Two other etiologies are identified with significance to treatment, and the role of craniotomy is discussed.