Pneumocephalus in patients with orthostatic headache

Chronic Pediatric Headache as a Manifestation of Shunt Over-Drainage and Slit Ventricle Syndrome in Patients Harboring a Cerebrospinal Fluid Diversion System: A Narrative Literature Review

The main subject of the current review is a specific subtype of headache, which is related to shunt over-drainage and slit ventricle syndrome, in pediatric patients harboring an implanted shunt device for the management of hydrocephalus. This clinical entity, along with its impairment regarding the quality of life of the affected individuals, is generally underestimated. This is partly due to the absence of universally agreed-upon diagnostic criteria, as well as due to a misunderstanding of the interactions among the implicated pathophysiological mechanisms. A lot of attempts have been performed to propose an integrative model, aiming at the determination of all the offending mechanisms of the shunt over-drainage syndrome, as well as the determination of all the clinical characteristics and related symptomatology that accompany these secondary headaches. This subcategory of headache, named postural dependent headache, can be associated with nausea, vomiting, and/or radiological signs of slim ventricles and/or subdural collections. The ultimate goal of our review is to draw clinicians' attention, especially that of those that are managing pediatric patients with permanent, long-standing, ventriculoperitoneal, or, less commonly, ventriculoatrial shunts. We attempted to elucidate all clinical and neurological characteristics that are inherently related to this type of headache, as well as to highlight the current management options. This specific subgroup of patients may eventually suffer from severe, intractable headaches, which may negatively impair their quality of daily living. In the absence of any other clinical condition that could be incriminated as the cause of the headache, shunt over-drainage should not be overlooked. On the contrary, it should be seriously taken into consideration, and its management should be added to the therapeutic armamentarium of such cases, which are difficult to be handled.

Spinal procedures, pneumocephalus, and cranial nerve palsies: A review of the literature

Purpose: Minimally invasive and surgical spine procedures are commonplace with various risks and complications. Cranial nerve palsies, however, are infrequently encountered, particularly after procedures such as lumbar punctures, epidural anesthesia, or intrathecal injections, and are understandably worrisome for clinicians and patients as they may be interpreted as secondary to a sinister etiology. However, a less commonly considered source is a pneumocephalus which may, in rare cases, abut cranial nerves and cause a palsy as a benign and often self-resolving complication. Here, we present the case of a patient who underwent an intrathecal methotrexate infusion for newly diagnosed non-Hodgkin's T-cell lymphoma and subsequently developed an abducens nerve palsy due to pneumocephalus. We highlight the utility of various imaging modalities, treatment options, and review current literature on spinal procedures resulting in cranial nerve palsies attributable to pneumocephalus presenting as malignant etiologies.

Management of Slit Ventricle Syndrome: A Single-Center Case Series of 32 Surgically Treated Patients

OBJECTIVE

Slit ventricle syndrome (SVS) is an iatrogenic disease occurring in patients with ventriculoperitoneal shunt. This article reports the management modalities and results in a case series from a single center.

METHODS

We reviewed a series 48 hospitalized patients with severe SVS whom we managed in a 10-year period. Thirty-seven patients harboring programmable valves (P-valves) first underwent attempts at valve reprogramming. This treatment produced no effect in 21 patients, who therefore required surgical treatment. Surgery was also required by 11 patients without P-valve. Accordingly, 32 patients had to be operatively treated by shunt externalization followed by valve replacement or endoscopic third ventriculostomy basing on intracranial pressure and ventricular size. The new valve was either ProGav Mietke (Aesculap) or Medos Codman (Integra), each equipped with its own antisiphon system. In selected cases, a programmable antisiphon system (ProSa Mietke) was used.

RESULTS

Surgical mortality was 3% and major morbidity accounted for 6%. Complete resolution was obtained in 55% of cases, improvement in 32%, and no effect or worsening in 13%. Only 1 patient became shunt free after endoscopic third ventriculostomy. Medos and ProGrav provided comparable outcomes, whereas ProSa was determinant in selected cases. Pediatric age, uncomplicated shunt courses, and short SVS histories were significantly favorable indicators.

CONCLUSIONS

SVS management remains problematic. However, this study individuated factors that may improve the outcome, such as wider use of P-valves to treat hydrocephalus, timely diagnosis of overdrainage, and earlier and more aggressive indications to manage SVS.

Seizures following cervical laminectomy and lateral mass fusion: case report and review of the literature

Incidental durotomy can occur as a complication of spine surgery, which may potentially result in serious intracranial complications. We report a case of a 72 years old male with significant cervical spinal stenosis from C3 to C5 with spinal cord myelomalacia who underwent a posterior cervical decompression with instrumentation and fusion from C3-C5. An incidental dural tear was encountered during the surgery, with a sudden gush of cerebrospinal fluid (CSF) managed intraoperatively. Unfortunately, he developed generalized tonic-clonic seizures subsequently in the immediate post-operative period. Computerized tomography (CT) scan was urgently done which revealed intracranial pneumocephalus, subarachnoid hemorrhage and a right acute subdural hematoma. This case illustrates the intracranial hemorrhage potential subsequent to iatrogenic dural tear and CSF leak manifested by generalized seizures. The repair of incidental durotomy should be done immediately to decrease the amount of CSF leak and prevent any devastating effects of intracranial hemorrhage. The mechanism of this type of bleeding, risk factors and appropriate management are discussed, along with a review of the literature.

Pneumocephalus secondary to a spinal surgery: A literature review and a case report

Introduction

We report a case of pneumocephalus, which is identified as the presence of air in the cranial cavity and is a rare complication after spinal surgeries, in addition to a literature review of similarly reported cases.

Case presentation

The patient is a 63-year-old male who developed pneumocephalus after undergoing a minimally invasive left side decompression at L3-L4 with left L4 foraminotomy even though there were no signs of dural tears or Cerebrospinal Fluid (CSF) leaks. After the diagnosis of pneumocephalus using brain Magnetic Resonance Imaging (MRI), the patient was treated conservatively and was discharged after 3 weeks without developing further complications.

Discussion

Pneumocephalus is defined as an abnormal accumulation of air within the cranial cavity. It can occur due to a variety of causes but rarely due to gas forming bacteria. Many theories are suggested concerning the pathophysiology of pneumocephalus, the inverted bottle theory, the ball valve theory, the Nitrous Oxide (N₂O) theory, and as we outweigh in our case, gas forming bacteria theory. Pneumocephalus can be treated surgically, nevertheless, conservative management methods of such cases are usually followed.

Conclusion

The aim of this study is to draw further attention to the management and diagnosis of such surgical complication. A more extended research is needed to provide a full comprehensive approach to deal with this problem if faced in the future. To the best of our knowledge, this study reports the first pneumocephalus case induced by a postoperative bacterial infection in the global English based medical literature.

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Pneumocephalus caused by gas forming infection in the spine is a rare complication after spinal surgery.

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Unexplained headache spinal surgeries should raise suspicion toward pneumocephalus.

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There are many theories regarding the development of pneumocephalus, each one need specific attention.

Pneumocephalus associated with epidural and spinal anesthesia for labor

Headache resulting from dural puncture in epidural and spinal anesthesia is usually secondary to a CSF leak. Pneumocephalus may also occur in this setting but has not been well-characterized. Although the risk factors for a CSF leak and pneumocephalus may overlap, their rates, clinical features, and treatments may be different. Our retrospective review of 182 patients with acute headache in the antepartum, peripartum, and postpartum settings yielded a 5:1 ratio of postdural puncture headache to pneumocephalus. The 3 patients with pneumocephalus had the defining characteristic of thunderclap headache during anesthesia. Early diagnosis is helpful as treatment with supplemental oxygen may hasten recovery. Pneumocephalus should be considered as a possible etiology of thunderclap headache in the setting of epidural and spinal anesthesia.

Case Report: Pneumocephalus after labor epidural anesthesia

Lumbar epidural anesthesia is commonly used for labor analgesia. The 'loss-of- resistance' to air technique (LORA) is generally employed for recognition of the epidural space. One of the rare complications of this technique is pneumocephalus (PC). Here we describe the case of a parturient who developed a frontal headache when locating the epidural space using LORA. On the second day after epidural injection, the patient exhibited occipital headaches with gradual worsening. Computed tomography scans of the brain indicated PC. Following symptomatic treatment, our patient was discharged on the 13th day. We concluded that the amount of air used to identify the epidural space in LORA should be minimized, LORA should not be used after dural puncture and the use of saline avoids PC complications.

Pneumocephalus in a patient with no cerebrospinal fluid leakage after lumbar epidural block - a case report -

Several complications are possible after a lumbar epidural block. However pneumocephalus are rare. In this case, we report a case of pneumocephalus. A 68-year-old male patient received lumbar epidural block with the loss of resistance technique using air, and after 35 minutes, apnea, unconsciousness, hypotension, and bradycardia occurred. Immediately, brain CT was done, and we found pneumocephalus. The patient complained of severe occipital headache and itchiness due to pneumocehalus. After conservative treatment, the patient recovered without neurologic complications, and on the seventh day of his hospitalization, he was discharged from the hospital.

Intracranial subdural hematoma and pneumocephalus after spinal instrumentation of myelodysplastic scoliosis

To report a case of acute intracranial subdural hematoma, pneumocephalus, and pneumorachis, which occurred because of cerebrospinal fluid (CSF) leak caused by a malpositioned transpedicular screw during spinal surgery for severe myelodysplastic scoliosis accompanied with hydrocephalus. Intracranial hemorrhage may occur as a consequence of dural sac penetration and CSF leakage after various medical procedures at the spinal level. The awareness of this severe complication is especially important during spinal instrumentation procedures in which inadvertent dural sac violation and CSF loss may be overlooked. A case report and literature review are presented here. A 12-year-old girl with a history of myelomeningocele and hydrocephalus underwent instrumentation for severe myelodysplastic scoliosis. Postoperatively, she became aphasic and increasingly somnolent. An urgent computed tomographic scan of the head and spine showed massive intracranial hematoma, pneumocephalus, pneumorachis, and a malpositioned pedicular screw that caused CSF leakage, intracranial hypotension, and bleeding remote from the surgical site. The patient needed neurosurgical cranial decompression and subsequent spinal reoperation with dural tear repair. The final outcome was an uneventful complete recovery. The increasing use of pedicular screws in spinal surgery carries a potential risk of occult dural sac violation with subsequent CSF leakage, intracranial hypotension, and the possibility of intracranial bleeding and pneumocephalus remote from the surgical site. This potentially fatal complication should always be considered after spinal surgery in the presence of early signs of neurological deterioration and necessitates an urgent cranial and spinal imaging to confirm the diagnosis and to make adequate treatment decisions.