Traumatic tension pneumocephalus - Two cases and comprehensive review of literature

Pediatric orbital emphysema and pneumocephalus following a compressed air gun injury: a case report

BACKGROUND

Orbital emphysema and pneumocephalus rarely occur without associated skull fractures. Over the past decades, a few case reports have documented compressed air injuries as a rare cause of orbital emphysema and pneumocephalus in the absence of concomitant skull fractures leading to various injuries.

CASE PRESENTATION

We illustrate here a 12-year-old boy who presented with painless left eye swelling following an accidental compressed air blast injury. On examination, he exhibited mild bilateral visual acuity impairment. The left eyelids, periorbital region, and cheeks were swollen, with swelling extending to the jaw with palpable crepitations. Ocular motility of the left eye was restricted in all directions. Slit lamp examination revealed subconjunctival hemorrhage, air bubbles, and chemosis, while the cornea, anterior chamber and lens were normal. Pupillary reactions were brisk. Fundus examination and intraocular pressure were normal. The right eye and adnexa were completely normal. The patient had no neurological symptoms. NCCT scan revealed left frontal and temporal subcutaneous emphysema, bilateral orbital emphysema, and multiple gas foci in the left masticator, parotid and carotid spaces, as well as in both parapharyngeal spaces. Pneumocephalus was noted in the left temporal lobe, along the left cavernous sinus and parasellar region without bony fractures. The patient underwent surgical exploration of the sclera of the left globe under general anesthesia to exclude the presence of a scleral wound under subconjunctival hemorrhage and air bubbles and he was free. The patient was managed conservatively with instructions for bed rest, head elevation, and avoidance of the Valsalva maneuver. Gradual improvement was reported over follow-up, with the patient returning to normal after four weeks.

CONCLUSIONS

Both orbital emphysema and pneumocephalus can occur in rare instances without skull fractures. The symptoms can range from mild to life-threatening. Mild cases can be managed conservatively.

Profound Pneumocephalus and Low-Pressure Hydrocephalus Triggered by Ventriculoperitoneal Shunt Placement after Resection, Fat Graft Reconstruction, and Radiotherapy for a Malignant Skull Base Schwannoma

Background  Tension pneumocephalus is a rare postoperative complication, typically presenting with mental status changes or rapid neurological decline after craniotomy. We report a complex case of tension pneumocephalus triggered by graft retraction after ventriculoperitoneal (VP) shunt placement. Case History  A 39-year-old woman with a recurrent left trigeminal cavernous sinus schwannoma, status post one prior resection, two stereotactic radiosurgery treatments, and one course of fractionated radiotherapy, underwent radical resection with orbital exenteration and abdominal fat free graft reconstruction followed by adjuvant radiotherapy for malignant transformation. She developed subacute ventriculomegaly with altered mental status, prompting VP shunt placement. Three weeks later, she presented with profound pneumocephalus and intraventricular air originating from a large, left-sided sphenoid and maxillary defect, from which the fat graft had retracted. A right frontal external ventricular drain (EVD) was placed, resulting in immediate release of air under high pressure. Definitive treatment required skull base reconstruction with a latissimus dorsi free flap, contralateral nasoseptal flap, antibiotics, and VP shunt revision for treatment of combined cerebrospinal fluid (CSF) leak, pneumocephalus, ventriculitis, and low-pressure hydrocephalus. As of her last follow-up, she was restored to her initial postresection neurological baseline. Conclusion  Tension pneumocephalus is a rare and life-threatening emergency that requires immediate neurosurgical intervention. We report the index case of tension pneumocephalus induced by graft retraction following radiotherapy and CSF diversion. Where observed, tension pneumocephalus resulting from a skull base CSF leak may be associated with low-pressure hydrocephalus, and successful long-term management demands balancing the need for CSF diversion against the integrity of the skull base reconstruction.

Untreated tension pneumoventricle leading to progressive encephalomalacia: a rare case report with review of literature

Tension pneumoventricle is a rare but potentially life threatening condition affecting the central nervous system.The majority of the reported cases are iatrogenic, seen after surgery for posterior fossa tumours, particularly in sitting position and pituitary and skull base tumours.Tension pneumoventricle following head injury is very rare with only seven reported cases till date. We report a case of untreated tension pneumoventricle, resulting from head injury due to road traffic accident leading to encephalomalacia of both the frontal lobes.

Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report

PURPOSE

Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH).

CASE PRESENTATION

An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day.

CONCLUSION

TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.

Traumatic tension pneumocephalus: a case report and perspective from Indonesia

Traumatic tension pneumocephalus is a rare and life-threatening complication of traumatic brain injury necessitating prompt diagnosis and neurosurgical treatment. Nevertheless, various possibilities for impedance in timely management, including patient-related barriers are commonly experienced in low-and middle-income countries setting. Here we presented a delay of management in traumatic tension pneumocephalus case due to initial refusal for emergency surgery. A 59-year-old male presented to the emergency department following a motorcycle accident fully alert with no neurological deficit. He acknowledged clear nasal discharge within 1 h after the initial trauma, but no rhinorrhea or otorrhea was present during physical examination. Head CT revealed extensive pneumocephalus with "Mount Fuji sign," anterior skull base fracture, and frontal sinus fracture. The patient initially refused immediate surgical intervention due to excellent clinical condition and financial scare. Acute decrease of consciousness occurred 40 h post-trauma: GCS of 6 with slight dilatation of both pupils (4 mm) and sluggish pupillary reflex. Emergency bifrontal craniotomy, subdural air drainage, and dura mater tear repair were performed afterwards. Postoperative care was uneventful, with rapid improvement of consciousness and follow-up head CT showing minimal subdural fluid collection and absence of remaining pneumocephalus. The patient was discharged from the hospital after 7 days with GCS of 15 and GOS of 5, proving the importance of overcoming barriers for delay in delivering neurotrauma care in low-and middle-income countries.

Transnasal Endoscopic Treatment of Tension Pneumocephalus Caused by Posttraumatic or Iatrogenic Ethmoidal Damage

Background

Tension pneumocephalus is a neurosurgical emergency caused by progressive accumulation of air in the intracranial spaces mediated by a valve mechanism. Tension pneumocephalus usually presents with headaches, reduced consciousness, and even death. One of the most common causes is an ethmoidal defect resulted by nasal surgery or facial traumas.

Methods

A literature review about tension pneumocephalus resulting from ethmoidal damages was performed. Surgery strategies included decompression by frontal burr holes and multilayer repair of the ethmoidal defect. In this paper, an endoscopic technique that exploits the ethmoidal defect to decompress the intracranial spaces and to resolve tension pneumocephalus with fewer complications and shorter hospitalization in comparison to frontal craniotomy is proposed.

Conclusion

The proposed endonasal endoscopic technique could be effectively used as a first-line treatment for symptomatic tension pneumocephalus caused by posttraumatic or iatrogenic ethmoidal defect.

From Eardrum to Cranium: Pneumocephalus Secondary to Acute Otitis Media

Pneumocephalus, or air entrapment within the cranium, is a rare but dangerous condition with a variety of causes, including trauma, surgery, or predisposing infection. Trauma is the most common etiology, as fractures provide easy access for air to become entrapped in the cranium. However, access such as via the central nervous system with leak exists. Though not as common as traumatic pneumocephalus, pneumocephalus secondary to infection is a dangerous condition. The literature is sparse on this example of ear-nose-throat infection, making it difficult to form and ascertain guidelines for the management of infectious pneumocephalus and its complications. A 58-year-old man with a history of hypertension, obesity, type 2 diabetes mellitus, and obstructive sleep apnea who presented with a complicated case of acute otitis media associated with subdural empyema, pneumocephalus, and group A Streptococcus is presented in this case report. We describe the course of his hospital stay, management, and current infectious disease guidelines. Given the paucity of cases of infectious pneumocephalus secondary to otitis media, we aim to provide further representation for this important illness as well as encourage the use of a multimodal team of providers. In our case, it was necessary to involve the ear-nose-throat specialist as well as infectious disease and neurocritical care services.

Pneumocephalus With Stroke-Like Symptoms: A Rare Complication of Mastoiditis

Pneumocephalus is defined as the presence of gas or air in the intracranial space and typically arises as a result of neurotrauma. Clinically, pneumocephalus most often presents asymptomatically but may cause headache, nausea, vomiting, and confusion. Pneumocephalus arising from mastoiditis is an unforeseen complication with only a handful of cases reported. We report a case of an elderly male who presented with stroke-like symptoms in the setting of erosive mastoiditis with pneumocephalus.

Pneumocephalus secondary to epidural analgesia: a case report

INTRODUCTION

Epidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a rare and potentially serious complication of epidural anesthesia, which is most often caused by accidental puncture of the dura with the introduction of air into intrathecal space.

CASE PRESENTATION

We present the case of a 19-year-old Hispanic female who developed a severe frontal headache and neck pain eight hours following epidural catheter placement to deliver analgesia during labor. Physical examination was within normal limits without any neurological deficits. Computed tomography of the head and neck would later demonstrate small to moderate amounts of pneumocephalus, predominantly within the frontal horn of the lateral ventricles, and a moderate amount of air within the spinal canal. She was treated conservatively with analgesia. Though headache recurred after discharge, repeat imaging showed improvement in the volume of pneumocephalus and conservative management was continued.

CONCLUSIONS

Although a rare complication and an uncommon cause of headache following epidural anesthesia, a high index of suspicion must remain for pneumocephalus as it may cause significant morbidity and, in some cases, be potentially life-threatening.

Delayed Posttraumatic Tension Pneumocephalus: Case Report and Review of Literature

Delayed tension pneumocephalus is a rare entity. Twelve cases of posttraumatic delayed tension pneumocephalus have been reported. This study is a case report of a patient presenting with delayed posttraumatic tension pneumocephalus, and highlights the nuances of management.

Pneumocephalus following sneeze suppression

Pneumocephalus is defined as air in the intracranial space. It is commonly caused by traumatic skull fractures and is diagnosed by head plain computer tomography. Treatment involves initial stabilization of vital signs and surgical intervention if symptoms do not resolve. We report a unique case of pneumocephalus following sneeze suppression.

Posttraumatic Tension Pneumocephalus Causing Atropine-Resistant Bradycardia

Pneumocephalus is a serious complication following brain trauma. Tension pneumocephalus (TP) is entrapment of a large volume of air in the cranial vault causing mass effect on the brain parenchyma. It is the intracranial counterpart of tension pneumothorax and if neglected, can be life threatening. TP should be timely differentiated from benign pneumocephalus owing to its various nonspecific and lethal complications. Our patient is a 37-year-old male with a history of road traffic accident who presented to our hospital with headache and nasal discharge for the last two days. Computed tomography showed multiple skull fractures and extensive pneumocephalus. His preoperative heart rate was 38 beats per minute that was resistant to pharmacological interventions and required a temporary pacemaker for surgery. He underwent uneventful craniotomy for dura repair and was discharged home with no neurological deficit.

Delayed Postoperative Tension Pneumocephalus Treated With a Subdural Evacuating Port System: A Case Report and Review of the Literature

Tension pneumocephalus (TP) is a rare neurosurgical emergency due to the rise of intracranial pressure from air in the cranial cavity. Tension pneumocephalus' clinical presentation ranges from headache, visual alterations, altered mental status, and death. Given its nonspecific clinical presentation, tension pneumocephalus is usually diagnosed via computed tomography (CT) imaging. Open burr hole craniotomy is the preferred treatment method for tension pneumocephalus. Subdural evacuating port system (SEPS) drains have, however, seen increased utilization in neurosurgery due to decreased possibilities for infections, reduced seizure probability, and better outcomes post-surgery, especially for elderly patients. In this article, we present the case of a 67-year-old female with postoperative tension pneumocephalus after the evacuation of an acute subdural hematoma. The patient became symptomatic from tension pneumocephalus, which was evacuated using a subdural evacuating port system drain. Post-drain placement, the patient had a radiographic and clinical resolution of her tension pneumocephalus. Thesubdural evacuating port system is a useful adjunctive tool for treating tension pneumocephalus.Given the favorable characteristic profile of subdural evacuating port system drains compared to open surgical modalities, further inquiry should be pursued to analyze the feasibility of establishing subdural evacuating port systems as a less invasive treatment alternative.

A Case of Delayed Tension Pneumocephalus in a Patient Undergoing Facial Cosmetic Surgery

There has been a recognizable surge in cosmetic surgery in recent years, partly influenced by social media, and the easy accessibility to such medical procedures. As with all types of surgery, the risks of complications are real, and in this specific setting, they tend to occur in a younger age group. Here, we discuss a rare complication and subsequent presentation of tension pneumocephalus, following an episode of cardiac arrest in a 58 year old female, during elective cosmetic-facial surgery. Typically, pneumocephalus develops when there are skull or facial bone fractures, and presents characteristically with leakage of cerebrospinal fluid from the ears and/or nose. The absence of the typical clinical signs and the lack of a clinical history or radiologically evidence of skull or facial bone fractions, may result in a delayed diagnosis, permanent brain injury and death. Awareness of such an unusual complication is therefore crucial when considering any surgery to the head and face (including cosmetic surgery), or following prolonged resuscitative efforts, which may well develop days after the inciting event.

Endoscopic Endonasal Eustachian Tube Obliteration as a Treatment for Tension Pneumocephalus After Translabyrinthine Resection of Vestibular Schwannoma

OBJECTIVE

Cerebrospinal fluid leak and pneumocephalus are rare but potentially devastating complications associated with translabyrinthine resection of cerebellopontine angle masses. Persistent pneumocephalus despite proximal eustachian tube (ET) obliteration is rare. We describe, to our knowledge, the first report of successful management of tension pneumocephalus by endoscopic endonasal ET obliteration using a novel V-loc (Covidien; Medtronic, Minneapolis, MN) suture technique.

PATIENTS

A 63-year-old man presented with altered mental status 10 months after translabyrinthine excision of a left cerebellopontine angle vestibular schwannoma measuring 2.8 × 2.9 × 3.3 cm. Computed tomography demonstrated diffuse ventriculomegaly and new pneumocephalus along the right frontal lobe, lateral ventricles, and third ventricle, and air within the left translabyrinthine resection cavity.

INTERVENTION

The patient underwent left-sided endoscopic endonasal ET obliteration using 2-0, 9-inch V-loc suture.

MAIN OUTCOME MEASURE

Postoperatively, the patient's mental status improved with a decrease in size of the lateral and third ventricles on computed tomography.

CONCLUSION

Endoscopic endonasal ET obliteration, a technique previously applied to recalcitrant cerebrospinal fluid leaks, is a safe and reasonable alternative to reentering the original surgical site for patients with pneumocephalus after lateral skull base surgery. Utilizing a V-loc suture for this technique instead of a traditional suture may improve procedural ease and speed.

Tension pneumocephalus: case report and review

Tension pneumocephalus is a rare complication of frontal sinus fracture or neurosurgical intervention resulting from compression of the brain by entrapped air, leading to seizure, altered mental status, brain herniation, and death. This report presents a case of traumatic tension pneumocephalus associated with an anterior and posterior table frontal sinus fracture in a patient with pneumosinus dilatans and osteogenesis imperfecta.

The Role of Endonasal Endoscopic Skull Base Repair in Posttraumatic Tension Pneumocephalus

OBJECTIVES

Information about the endonasal endoscopic approach (EEA) for the management of posttraumatic tension pneumocephalus (PTTP) remains scarce. Concomitant rhinoliquorrhea and posttraumatic hydrocephalus (PTH) can complicate the clinical course.

METHODS

The authors systematically reviewed pertinent articles published between 1961 and December 2020 and identified 6 patients with PTTP treated by EEA in 5 reports. Additionally, the authors share their institutional experience including a seventh patient, where an EEA resolved a recurrent PTTP without rhinoliquorrhea.

RESULTS

Seven PTTP cases in which EEA was used as part of the treatment regime were included in this review. All cases presented with a defect in the anterior skull base, and 3 of them had concomitant rhinoliquorrhea. A transcranial approach was performed in 6/7 cases before EEA was considered to treat PTTP. In 4/7 cases, the PTTP resolved after the first intent; in 2/7 cases a second repair was necessary because of recurrent PTTP, 1 with and 1 without rhinoliquorrhea, and 1/7 case because of recurrent rhinoliquorrhea only. Overall, PTTP treated by EEA resolved with a mean radiological resolution time of 69 days (range 23-150 days), with no late recurrences. Only 1 patient developed a cerebrospinal fluid diversion infection probably related to a first incomplete EEA skull base defects repair. A permanent cerebrospinal fluid diversion was necessary in 3/7 cases.

CONCLUSIONS

Endonasal endoscopic approach repair of air conduits is a safe and efficacious second-line approach after failed transcranial approaches for symptomatic PTTP. However, the strength of recommendation for EEA remains low until further evidence is presented.

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.

Traumatic Pneumocephalus Without Skull Fracture From a High-Voltage Electrical Injury

Pneumocephalus, the presence of intracranial air, most commonly occurs secondary to a traumatic injury. Patients with simple pneumocephalus often present with nonspecific symptoms or with headaches. These patients may have little to no clinically relevant physical examination findings and can be managed conservatively. Tension pneumocephalus can present more acutely as a neurosurgical emergency. On physical examination, patients can present with neurologic deficits or papilledema. Computed tomography is the imaging modality of choice to detect intracranial air. We present a novel case of a simple pneumocephalus in the setting of a high-voltage electrical injury without evidence of displaced skull fracture or dural violation. The identification of unanticipated air within the cranial vault should prompt emergency physicians to determine its etiology which can guide treatment and disposition.

Expanding pneumocephalus due to craniofacial fractures: A case report

Introduction

Pneumocephalus (PNC) is the presence of air in the intracranial cavity. The most frequent cause is craniofacial trauma, though there are many etiologies, including surgical procedures. PNC with compression of the frontal lobes and widening of the interhemispheric space between the tips of the frontal lobes results in the characteristic radiological finding of the “Mount Fuji sign”.

Presentation of case

A 57-year-old man presented to the A&E with loss of consciousness due to a motorcycle collision 9 h prior. He had a GCS of E4M6V5, and a head CT scan revealed minimal PNC forming in both hemispheres. After discharge, severe headaches and rhinorrhea developed. A second CT scan revealed a massive PNC. An operation was then performed via a bicoronal incision to drain the PNC and seal the cranial defect. A burr hole in the calvarium was created, and the cranial defect was closed using a pericranial rotational flap. Post-operation, the patient's headache and rhinorrhea decreased; neither symptom was present at 1-month post-operation. The wounds healed with minimal scarring, and the cosmetic outcome for the craniofacial fracture was acceptable.

Discussion

Although the patient may at first present with a mild head injury, this can progress into something much more serious. PNC is difficult to diagnose clinically. Rarely, patients describe a splashing sound upon moving the head (termed bruit hydro-aerique), which can also be auscultated. A head CT scan is the gold standard in the diagnosis of PNC. Pericranial flaps are widely used for dural repair because they are easily accessible and have a lower rate of infection than artificial grafts on expanding PNC.

Conclusion

Tension PNC may be slow-growing and increase intracranial pressure to high levels before clinical signs are present. The pericranial rotational flap technique is the best way to close a dura mater defect in cranial base fractures with tension PNC.

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Pneumocephalus (PNC) is the presence of air in the intracranial cavity.

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Craniofacial trauma is the most frequent cause of PNC.

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We report a male with expanding PNC who required a pericranial rotational flap.

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Tension PNC may be slow-growing and increase intracranial pressure to high levels before clinical signs are present.

Rare Case of Tension Pneumocephalus in Thoracic Trauma

Tension pneumocephalus is the presence of air within the cranial vault compressing the ventricles and the brain parenchyma. High altitudes can exacerbate this problem, especially when a dural defect exists and air is forced into the cranial cavity with no way to escape. This case demonstrates a rare presentation of thoracic trauma causing tension pneumocephalus due to emergent air evacuation.

Delayed post-traumatic Tension Hydropneumocephalus; a Case Report of Conservative Treatment

Pneumocephalus refers to the presence of air in the cranial cavity. Trauma is the most common cause of acquired pneumocephalus. Tension pneumocephalus occurs when intracranial accumulation of air causes high pressure on the brain as compared to extracranial pressure. Tension pneumocephalus is usually acute, and causes neurological symptoms, and its delayed form rarely occurs. A 12-year-old girl presented with a headache, lethargy, mild fever, and nausea from two days before admission to emergency department of Shahid Rajaei Hospital, Qazvin, Iran. The patient had a history of head trauma in a driving accident six weeks before and had undergone brain computed tomography (CT) scan in another centre, which had revealed no sign of pneumocephalus. The patient had been treated for one week and had been discharged in good general condition.

Considering her reduced consciousness, the patient underwent brain CT scan again in our centre. CT scan revealed tension hydropneumocephalus. The patient was transferred to the intensive care unit (ICU) for treatment. Considering the trend of her recovery, the patient was a candidate for conservative non-surgical therapy based on the in-charge neurosurgery specialist’s decision. The patient reported no complications during the six-month follow-up. Delayed tension pneumocephalus is among neurosurgery emergencies usually treated with early surgical intervention and dura defect restoration, but this patient received non-surgical treatment without any serious problem during the six-month follow-up.

Tension pneumocephalus and bilateral orbital compartment syndrome relieved by lateral canthotomies

Traumatic tension pneumocephalus and orbital compartment syndrome are rare, tend to be associated with severe craniofacial injuries, and can occur following both blunt and penetrating injury. Early recognition and high index of clinical suspicion are important in both cases. Emergency decompression results in improvement in vast majority of cases.

Beware of the 3776.24 m peak

A middle-aged man presented to the emergency department after a seemingly trivial head injury. Recognition of pathognomonic radiological findings allowed early diagnosis of a potentially life-threatening condition. The patient recovered uneventfully after prompt neurosurgical intervention.

Endoscopic Skull Base Repair Strategy for CSF Leaks Associated with Pneumocephalus

Background: Cerebrospinal (CSF) fluid leaks with associated pneumocephalus (PNC) represent a condition bearing serious risks for the patient, with little data available in the literature. Reported success rates of endoscopic skull base repair are lower when PNC is associated than in the case of simple CSF leaks. The present study represents an analysis of our experience with endoscopic management of this condition. Methods: Records of patients with pneumocephalus and associated CSF leaks, who underwent endoscopic skull base repair, were reviewed. Demographics, history, etiology of PNC, size of defect, surgical approach, reconstruction technique and complications were evaluated. Results: Twenty patients with CSF leaks and PNC underwent endonasal repair by the senior author between 2005 and 2019. Defect size was larger than 15 mm in all cases. All patients presented either worsening of PNC under conservative treatment or tension PNC. First-attempt closure of the defect was successful in all patients (100%), with resolution of the pneumocephalus. One patient developed a synechia in the proximity of the frontal ostium, as a postoperative complication. The mean follow-up was 39 months (range: 15–94 months). Conclusion: The present study represents a proposed argument for earlier endoscopic endonasal treatment in patients presenting CSF leaks and pneumocephalus.

A Case of Atraumatic, Streptococcal Pneumocephalus: A Rare Complication of Influenza B Infection

Patient: Female, 51-year-old

Final Diagnosis: Pneumocephalus • Pneumococcal meningitis

Symptoms: Worsening of mental status

Medication:—

Clinical Procedure: —

Specialty: Critical Care Medicine • Infectious Diseases • General and Internal Medicine

Tension Pneumocephalus from Endoscopic Endonasal Surgery: A Case Series and Literature Review

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.

Otogenic Pneumocephalus After Tegmen Bone Reconstruction: A Case Report

Pneumocephalus is usually induced by trauma, infections, tumors of the skull base, and surgical interventions. Spontaneous pneumocephalus occurs due to a defect in the temporal bone with no obvious cause. Few cases have been reported with spontaneous otogenic pneumocephalus. However, delayed postoperative pneumocephalus is rarely reported in the literature. Here, we present a case of otogenic pneumocephalus through Eustachian tube (ET) preceded by nose blowing 10 days after surgical treatment of meningoencephalocele of the right middle ear (ME) cleft and reconstruction of tegmen and dural defects. Pneumocephalus was provoked by decreased intracranial pressure (ICP) secondary to placement of lumbar drain, which caused direct communication between unsutured dural defect and the defective posterior wall of external auditory canal skin. A revision surgery of combined transmastoid/middle cranial fossa approach was performed for intracranial decompression followed by appropriate closure by suturing the dura, obliterating the ET and ME.

A Case of Traumatic Pneumocephalus on the Opposite Side of the Injury Site

Pneumocephalus is defined as an abnormal presence of intracranial air or gas. Traumatic pneumocephalus (TP) typically occurs on the injured side and is in communication with the external environment. This report presented an extremely rare case of TP that occurred on the opposite side of the injured site, even with the absence of any traumatic injury. The patient sustained injuries, including linear skull fracture, acute epidural hematoma, fractures in the clavicle and scapula, and subcutaneous emphysema, on the left side of the body. However, TP occurred on the right side. Although the exact underlying pathogenic mechanism remains unclear, the condition might be attributed to the migration of air bubbles or negative pressure on the opposite side caused by side-to-side closed head injury.

Management of moderate and severe traumatic brain injury

Traumatic brain injury (TBI) is a common disorder with high morbidity and mortality, accounting for one in every three deaths due to injury. Older adults are especially vulnerable. They have the highest rates of TBI-related hospitalization and death. There are about 2.5 to 6.5 million US citizens living with TBI-related disabilities. The cost of care is very high. Aside from prevention, little can be done for the initial primary injury of neurotrauma. The tissue damage incurred directly from the inciting event, for example, a blow to the head or bullet penetration, is largely complete by the time medical care can be instituted. However, this event will give rise to secondary injury, which consists of a cascade of changes on a cellular and molecular level, including cellular swelling, loss of membrane gradients, influx of immune and inflammatory mediators, excitotoxic transmitter release, and changes in calcium dynamics. Clinicians can intercede with interventions to improve outcome in the mitigating secondary injury. The fundamental concepts in critical care management of moderate and severe TBI focus on alleviating intracranial pressure and avoiding hypotension and hypoxia. In addition to these important considerations, mechanical ventilation, appropriate transfusion of blood products, management of paroxysmal sympathetic hyperactivity, using nutrition as a therapy, and, of course, venous thromboembolism and seizure prevention are all essential in the management of moderate to severe TBI patients. These concepts will be reviewed using the recent 2016 Brain Trauma Foundation Guidelines to discuss best practices and identify future research priorities.

[Management of complex skull base defects accompanied by pneumocephalus]

AIM

The study aim was to analyze our own experience in treating patients with complex skull base defects accompanied by pneumocephalus and, based on the findings, to develop an optimal treatment approach for this pathology.

MATERIAL AND METHODS

We retrospectively reviewed a series of 30 patients with complex skull base defects accompanied by pneumocephalus who underwent inpatient treatment at the Burdenko Neurosurgical Institute in the period from 2001 to 2017. We analyzed demographic characteristics of patients (gender, age), clinical data (etiology, somatic and neuropsychiatric status, radiological data), and treatment aspects (conservative or surgical treatment, used approach, defect characteristics, reconstructive materials). Treatment outcomes were assessed based on analysis of changes in clinical manifestations, postoperative complications, and recurrences. The obtained data were compared to the results of literature review.

RESULTS

In the series of 30 patients with complex skull base defects accompanied by pneumocephalus, the mean age was 41 years (range, 17-68 years); there were 17 (59%) males and 13 (41%) females. Etiologically, there were 17 (59%) traumatic cases, 11 (36%) iatrogenic cases, and 2 (5%) spontaneous cases. Clinically, the patients presented with the following manifestations: psycho-neurological symptoms (41%), nasal cerebrospinal fluid (CSF) leak (36%), impaired consciousness (27%), and meningitis (23%). Eight patients with acute injuries underwent complex conservative treatment that included infusion, and anti-edema, vascular, metabolic, anticonvulsant, and antibacterial therapy. In cases of conservative treatment failure or tension pneumocephalus accompanied by abrupt worsening of the patient's condition, surgical treatment was used. A total of 24 interventions (including revision surgery) were performed in 22 patients. All patients underwent endoscopic endonasal reconstruction of complex skull base defects. Tissues used for reconstruction included the fascia lata and adipose tissue (77%), fascia lata and cartilage/bone from the nasal septum (14%), and a pedicled nasoseptal flap (9%). The success rate of reconstructive interventions was 91%. There were 2 (9%) recurrences. Postoperative complications in the form of meningitis occurred in 4 (18%) patients.

CONCLUSION

In the case of a nasal cerebrospinal leak history and worsening of the patient's condition accompanied by common cerebral and psychiatric symptoms, the development of pneumocephalus should be considered first, the early diagnosis of which will facilitate choosing the correct treatment approach. In the case of acute injury in patients with the established diagnosis of pneumocephalus caused by gas-forming infection, conservative therapy is indicated in the early period after neurosurgical interventions with opening of the meninges. Tension pneumocephalus together with a skull base bone defect (according to CT) and a nasal CSF leak history is the indication for surgical treatment. In this case, the endoscopic endonasal technique is the method of choice.

Tension Pneumocephalus: A Rare Complication of Transsphenoidal Resection of a Pituitary Macroadenoma

Tension pneumocephalus (TP) is described as the presence of a large amount of air in the cranial cavity, compressing the parenchyma and ventricles. It is a rare neurosurgical emergency and has been reported in only a handful of cases as a complication of transsphenoidal resection of a pituitary adenoma. Our reported case is an addition to the series of those cases. A 60-year-old male patient underwent transsphenoidal resection of a pituitary macroadenoma. Computed tomography (CT) of the head performed post-procedure showed post-surgical changes with no identification of any acute intracerebral processes. On postoperative Day 2, the patient had a bout of sneezing and since that time, he was noted to be more altered in terms of his mentation and lethargic with no focal neurological deficits. A repeat CT of the head showed a large amount of air in the intracranial cavity compressing the brain parenchyma with slit-like appearances of the cerebral ventricles. The patient underwent emergent bifrontal air evacuation through burr holes. A cerebrospinal fluid leak was also noted while reconstructing the skull base. A postoperative CT scan showed marked resolution of TP. The patient improved clinically, was discharged home five days later, and was monitored closely by the surgical team on an outpatient basis.

Outcome of Posttraumatic Delayed Intracerebral Tension Pneumatocele: Prospective Study of Four Cases: Single Institutional Experience

Aim:

Delayed intracerebral tension pneumatocele (DITP) is an uncommon cause of raised intracranial pressure following trauma. However, it can cause herniation syndrome due to a sudden increase in intracranial pressure which requires emergent intervention. Pneumocephalus is a complication of head injury in 3.9%–9.7% of the cases. The accumulation of intracranial air can be acute (<72 h) or delayed (≥72 h).

Method:

When intracranial air causes intracranial hypertension and has a mass effect with neurological deterioration, it is called tension pneumocephalus. In our case series, we demonstrated four cases of DITP in adult patients from January 2012 to January 2017 in the Department of Neurosurgery at R. N. T. Medical College and M. B. Hospital, Udaipur, Rajasthan.

Result:

During this period, a total number of patients admitted of head injury are 1768 and hence, the incidence of DITP in our series is 0.226% which is very less as compared to previous literature. All patients are male; age ranging from 17 years to 55 years (mean age was 31.75 years). All patients have a history of head injury, and mode of injury had road traffic accidents. Glasgow Coma Score (GCS) at readmission were 12–13 (mean GCS 12.75). Duration of developed DITP 1 month to 2½ months (mean 1.375 months), all patients had gone to surgical intervention, and outcome assessed using Glasgow outcome score. All patients had a good outcome and average follow-up was 12.5 months.

Conclusion:

long term observation of patients with simple pneumocephalus following trauma is beneficial as there is an expected risk of developing delayed tension pneumocephalus which may manifest with raised intracranial pressure.

An unusual presentation of dystonia and chorea from intraventricular pneumocephalus

Background

Pneumocephalus is a common finding following intracranial procedures, typically asymptomatic and resolves within several days. However, in some cases, pneumocephalus presents with headache, encephalopathy, or symptoms of elevated intracranial pressure. Here, we present a case of iatrogenic tension pneumocephalus following endoscopic sinus surgery, presenting as abnormal involuntary movements resembling a movement disorder with choreiform movements.

Case Description

A 67-year-old previously healthy male presented with new onset chorea and dystonia associated with headache, encephalopathy, and postural instability 4 days after undergoing endoscopic sinus surgery for chronic sinusitis and nasal polyps. Computed tomography showed prominent intraventricular pneumocephalus causing enlargement of the anterior horns of both lateral ventricles with lateral displacement of the basal ganglia nuclei and a bony defect in the skull base. Neurosurgical correction of the cranial defect provided complete symptomatic resolution. Pneumocephalus as a result of an iatrogenic injury of the skull base manifesting as an acute movement disorder is a rare complication of a nasal sinus procedure. We speculate that compression of the caudate nucleus and striatum resulted in decreased pallidothalamic inhibition and thalamocortical disinhibition leading to the development of a hyperkinetic movement disorder.

Conclusion

This unusual presentation of a common procedure illustrates a neurological emergency that requires prompt recognition and timely correction.

Pneumocephalus Following Self-Inflicted Penetrating Brain Injury

Objective

Pneumocephalus is a rare complication that often occurs after traumatic skull base injury, leading to morbidity and mortality.

Material and Method

We present the case of a 42-year-old healthy man who injured himself when he stuck a metal stick into his left nasal cavity to relieve prolonged nasal obstruction. Immediate cerebrospinal fluid rhinorrhea and subsequent meningitis and pneumocephalus occurred later. He was presented at our hospital with fever and meningeal signs.

Result

Computed tomography scans revealed left rhinosinusitis and air collection in the subarachnoid space. The patient received the conservative treatment of bed rest, intravenous hydration, head elevation, and broad-spectrum intravenous antibiotics. Pneumocephalus and meningitis resolved without any surgery, and he experienced no other sequela or complication.

Conclusion

Pneumocephalus is a rare incidence and can lead to high morbidity and mortality. Prompt diagnosis and adequate treatment of pneumocephalus and meningitis proved beneficial for our patient who recovered without any complication or surgery.

Traumatic pneumocephaly: trapped air from where?

Traumatic pneumocephaly is literally defined as 'air in the head' after trauma. While this phenomenon has been well described in the literature, our case report is unique in describing diffuse pneumocephalus in the subaponeurotic space, subdural space, subarachnoid space, brain and ventricles without a break in the cranial vault: a 26-year-old man fell from a =9 meter scaffolding in a water tower. Following an arduous and delayed extrication, the patient was unresponsive with loss of pulse requiring intubation, cardiopulmonary resuscitation and release of tension pneumothorax with bilateral thoracostomy tubes. Examination remained poor with a Glasgow Coma Scale of 3. Immediate exploratory laparotomy was performed for a small right retroperitoneal haematoma on Focused Assessment with Sonography for Trauma. Postoperative imaging revealed diffuse pneumocephaly without facial fractures. This case presentation explores unusual causes of fistulous connections with the atmosphere that may lead to air trapped in and around the cranial vault.