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.

[Supraorbital approach to treat a fronto-orbital fracture with pneumocephaly, a minimal invasive technique]

We describe a supraorbital approach through an upper eyebrow skin incision to treat a fronto-orbital fracture with pneumocephaly in a 84-year-old cardiac patient. The clinical and cosmetic results are excellent. This case is illustrated by pre- and postoperative CT-scan and MRI as well as pictures showing the minimal invasive technique.

A 2-year-old boy with hemolytic uremic syndrome and pneumocephalus

Clostridium septicum infection following hemolytic uremic syndrome is rare and carries a poor prognosis, especially when the brain is involved. We report a case of a previously healthy 2-year-old boy who presented with two days of anuria and bloody diarrhea. He was admitted to the local children's hospital with a diagnosis of hemolytic uremic syndrome, presumably secondary to E. coli O157. He soon required intubation and was noted to have fixed and dilated pupils. Head CT revealed left frontal subcortical white matter vasogenic edema and scattered pockets of pneumocephalus. The patient expired 14 hours after admission. Antemortem blood cultures grew C. septicum. Gross pathologic examination of the brain revealed a large intraparenchymal cerebral hemorrhage in the left frontal and parietal lobes. There was extensive cystic changes as well. Microscopic examination revealed vacuolization and diffuse colonization with rod-shaped bacteria, but without the expected tissue response. There have been only six previously reported cases of C. septicum infection following hemolytic uremic syndrome, four of which had brain involvement. Mortality rate is high, with the only known survivor among those with brain involvement having a brain abscess rather than diffuse pneumocephalus.

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.

Endoscopic sinus surgery for a tension pneumocephalus after severe cranio-facial trauma

Tension pneumocephalus is a rare form of pneumocephalus in which the air is under pressure; it is generally due to communication between the atmosphere and the intracranial cavity, and is an infrequent (0.88%) complication of cranial trauma. Tension pneumocephalus causes an increase in intracranial pressure with deterioration of the neurological situation and requires emergency treatment. Endoscopic surgery of the paranasal sinuses, which is generally applied in the diagnosis and treatment of fistulas with cerebrospinal fluid leakage, was here used to treat a case of pneumocephalus due to cranio-ethmoidal communication, in a patient we had treated previously for severe cranio-facial trauma.

Otogenic tension pneumocephalus complicated by eustachian tube insufflation in a patient with a ventriculoperitoneal shunt. Case report

Spontaneous tension pneumocephalus (TPC) related to shunt surgery has sometimes been reported with reference to the Valsalva maneuver and osseous defects of the tegmen tympani. Here, the authors report on a case of TPC complicated by eustachian tube (ET) insufflation and a ventriculoperitoneal (VP) shunt. This 78-year-old man had undergone VP shunt insertion 3 weeks before readmission to the hospital with a diagnosis of TPC, a left temporal porencephalic cyst, and air accumulation and late leakage of cerebrospinal fluid (CSF) into the left tympanic cavity. The TPC was controlled successfully by ligation of the shunt tube. The authors discuss the pathophysiology of this complicated TPC case, which illustrates the risk of ET insufflation in patients undergoing CSF shunt surgery.

Symptomatic tension pneumocephalus: An unusual post-operative complication of posterior spinal surgery

Pneumocephalus is a rare, but serious complication of spinal surgery and its management and physiology is not widely recognized. Symptomatic tension pneumocephalus secondary to iatrogenic cerebrospinal fluid (CSF) leak after surgical intervention, and drainage with a vacuum suction device, has not been previously reported. We report a patient who underwent intervertebral disc surgery who developed pneumoencephalus after drainage with a vacuum suction device. Imaging showed significant pneumocephalus in the subarachnoid space of the frontal region and in the cisterns. The condition was resolved by discontinuation of the suction drainage, bed rest and hyperhydration. Thus, spinal drainage may predispose to entry of air intracranially and pneumocephalus. It is important to be aware of this serious post-operative complication in patients with a CSF fistula.

Pneumocephalus after Pancoast's tumor surgery: to be or not to be conservative?

We report a case of a 62-year-old man affected by Pancoast's tumor who developed pneumocephalus 17 days after right upper lobectomy with en bloc resection of the first three ribs and C8-D1 branches of the brachial plexus. The patient complained of aphasia, disorientation and sphincterial release. A chest and brain-CT scan showed a right apical pneumothorax associated with a massive pneumocephalus of the ventricles and of the subarachnoidal spaces. A pneumoperitoneum was also seen. The patient was treated using pleural drainages, Trendelenburg's position and antibiotic therapy. Clinical and radiological remission was achieved after 12 days of additional hospital stay.

Pneumocephalus and meningitis as a complication of acute otitis media: case report

Otogenic pneumocephalus is a rare condition. The case is described of pneumocephalus and meningitis secondary to acute otitis media. Although the rate of intracranial complications related to middle ear disease is only 0.5 to 4%, mortality still ranges between 5 and 15%.

Tension pneumoventricle

We report a case of tension pneumoventricle in a patient who underwent excision of a midbrain tectal plate tumour via a supracerebellar infratentorial approach while in the sitting position. Tension pneumoventricle was diagnosed when the patient's clinical condition deteriorated rapidly early in the postoperative period. An urgent computed tomography scan of the head revealed the presence of air in the frontal and temporal horns of the lateral ventricles and blood in the third and fourth ventricles. An emergency external ventricular drain insertion was performed, resulting in prompt recovery. We believe the contributing factors resulting in such rapid development of tension pneumoventricle were the patient's sitting position, pre-existing hydrocephalus, breach of the third ventricle during surgery and the presence of blood in the third and fourth ventricles.

Ventricular pneumocephalus and septic meningoencephalitis secondary to dorsal rhinotomy and nasal polypectomy in a dog

CASE DESCRIPTION

A 4-year-old sexually intact female French Bulldog was evaluated because of lethargy, anorexia, and chronic rhinitis-sinusitis. The dog had nasal discharge of 18 months' duration; dorsal rhinotomies were performed 3 months and 2 weeks prior to referral.

CLINICAL FINDINGS

On initial evaluation, intraventricular pneumocephalus and sinusitis were diagnosed; CSF analysis revealed high total protein concentration and mononuclear pleocytosis. The dog's condition improved with treatment. Two weeks after discharge, it was treated by a local veterinarian because of upper airway obstruction; 3 days later, the dog was referred because of seizures. Computed tomography revealed a large fluid-filled, left lateral ventricle and a soft tissue mass protruding through a cribriform plate defect. The mass was histologically consistent with brain tissue. Findings of clinicopathologic analyses were unremarkable. Results of cytologic examination of a CSF sample were indicative of septic, suppurative inflammation, and bacteriologic culture of CSF yielded Escherichia coli.

TREATMENT AND OUTCOME

Amputation of the herniated olfactory bulb and antimicrobial treatment resolved the septic meningoencephalitis, but neurologic deficits recurred 6 weeks later. Definitive correction of the cribriform plate defect with bone and fascial grafts was attempted. Postoperative rotation of the bone graft resulted in cerebral laceration and hemorrhage, and the dog was euthanized.

CLINICAL RELEVANCE

Findings suggest that following dorsal rhinotomy and nasal polypectomy surgery, the dog developed herniation of the left olfactory bulb, intra-ventricular pneumocephalus, and septic meningo-encephalitis because of a cribriform plate defect. Care must be taken to prevent rotation of bone grafts used in cribriform defect repair.

Tension pneumocephalus--the Mount Fuji sign

A 69-year-old female presented to the emergency department after becoming unresponsive at home following a progressive decrease in her level of consciousness (LOC) (See Figure 1). An urgent computerized tomography (CT) scan of the head demonstrated large bilateral chronic subdural hematomas (SDH’s). Due to the resulting mass effect she was brought urgently to the operating room where the SDH’s were evacuated via anterior and posterior burr holes placed bilaterally. No complications were encountered during the procedure. Prior to skin closure bilateral subdural catheters were placed in the posterior burr hole sites and left under closed suction.

Cerebellar haemorrhage and tension pneumocephalus after resection of a Pancoast tumour

We present an unusual case of cerebellar haemorrhage followed by tension pneumocephalus several days after thoracotomy for resection of a Pancoast tumour. The postoperative course of the 32-year-old patient was complicated by a cerebellar haemorrhage and hydrocephalus caused by compression of the fourth ventricle. Immediate surgical evacuation of the haemorrhage and placement of an external ventricular drain was performed. Respirator ventilation maintaining a continuous positive airway pressure was required. Following weaning and extubation the patient rapidly deteriorated and became comatose. A cranial CT scan revealed a dilated ventricular system filled with air, and air in the subarachnoid space. Recovery of consciousness was observed after aspiration of intracranial air through the ventricular drainage. Recurrent deterioration of consciousness after repeated air aspiration indicated rapid refilling of the ventricles with air. The patient underwent emergency surgical re-exploration of the thoracic resection cavity: dural lacerations of the cervico-thoracic nerve roots C8 and Th1 were identified. Subarachnoid-pleural fistula, cerebellar haemorrhage and tension pneumocephalus after discontinuation of continuous positive airway pressure respiration are unusual complications of thoracic surgery. We discuss the putative pathomechanisms and present a brief review of the literature.

Meningitis following basal skull fracture in two in-line skaters

INTRODUCTION

In-line skating has been reported to cause severe head injury. Basilar skull fracture (BSF) is associated with a high risk of complication.

CASE REPORT

We report two children who had bacterial meningitis following seemingly trivial in-line skating injuries. In both, anterior BSF was diagnosed retrospectively following occurrence of Streptococcus pneumoniae meningitis.

DISCUSSION

The clinical signs indicating BSF depend on the fracture location. Plain skull radiography and computed tomography (CT) are not sensitive enough to detect thin fractures in the anterior cranial fossa. We argue that high resolution multiple-plane CT and coronal T2-weighted magnetic resonance imaging are indicated to diagnose BSF.

Delayed isolated tension intraventricular pneumocephalus after ventriculoperitoneal shunt

OBJECTIVE AND IMPORTANCE

Delayed and isolated tension intraventricular pneumocephalus without air in the pericerebral subarachnoid spaces is an exceptional complication of a ventriculoperitoneal (VP) shunt. We purpose an explanation for the development of such delayed pneumocephalus.

CLINICAL PRESENTATION

A 14-year-old boy developed headaches and right-side hearing loss three months after surgical resection of a cerebellar medulloblastoma and insertion of a VP shunt. CT-scan showed isolated intraventricular pneumocephalus without air in the pericerebral subarachnoid spaces. A petrous bone defect was discovered and surgically repaired with clinical and radiographic resolution of pneumocephalus.

CONCLUSION

We presume that the brain tIssue plugging the bony defect retracted following the placement of the shunt and eventually there was rupture through the pia-mater into the lateral ventricle. This could explain why isolated intraventricular occurred, as opposed to air in the subarachnoid spaces.

Hyperpneumatization of the temporal, occipital and parietal bones

Hyperpneumatization of the temporal bone with extension into the occipital bone and even the parietal bones is a rare condition. According to a review of the literature, it mostly appears unilaterally in men and on the right side. Often it is discovered when complications like pneumatocele or pneumocephalus appear. The authors review and analyze all reported cases of hyperpneumatization, its symptoms, complications and treatment. We present a patient with extensive pneumatization found in the mastoid process, temporal bone, occipital bone and both parietal bones, who was discovered accidentally. The cause of the extension of pneumatization into the occipital and parietal bone is probably incomplete closure of the occipitomastoid synchondrosis and lambdoid and sagital sutures, which usually close in early adulthood and later, even in the 30s. Asymptomatic patients should be aware of possible complications, and in case of complications, operative therapy is often indicated.

Tension pneumocephalus following transsphenoid surgery for pituitary adenoma - report of two cases

Occurrence of symptomatic pneumocephalus following transsphenoid surgery is a rare event. Two cases of symptomatic pneumocephalus were observed in our series of 480 transsphenoidal surgeries. The first case reported presented with a head injury 4 years earlier and had a left frontotemporal haematoma evacuation. He underwent surgery for sellar mass extending into suprasellar region. He developed postoperative CSF rhinorrhea and in spite of conservative therapy, developed progressive visual deterioration necessitating a re-exploration and repair leading to resolution of the neurological deficits. The second case presented with delayed CSF rhinorrhea leading to rapid alteration in sensorium, requiring external ventricular drainage. The leak subsided without any further surgical intervention.

[Pictorial essay: Pneumocephalus]

Imaging in pneumocephalus aids in the diagnosis and management of this condition, which usually results from trauma, iatrogenic causes, infections, tumors, and cranium abnormalities. The role of computed tomography and magnetic resonance imaging is especially addressed in this article.

Symptomatic pneumocephalus occurring years after transphenoidal surgery and radiation therapy for an invasive pituitary tumor: a case report and review of the literature

We present the unusual case of a patient who experienced a CSF leak and subsequent pneumocephalus several years after transphenoidal surgery and radiation treatment for an ACTH secreting pituitary tumor. This patient underwent aggressive management including placement of a lumbar drain, and reoperation to stop her leak. Despite these efforts, her leak persisted resulting in significant tension pneumocephalus. Pneumocephalus is a rare but important potential complication of transphenoidal surgery. Here we discuss our management of this patient's condition, and review the existing literature.

Intraventricular tension pneumocephalus as a complication of transfrontal craniectomy: a case report

OBJECTIVE

To report the diagnosis and surgical treatment of a case of intraventricular tension pneumocephalus in a dog after a transfrontal craniectomy for removal of a falx cerebri meningioma.

STUDY DESIGN

Case report.

ANIMAL

A 12-year-old spayed English springer spaniel.

RESULTS

Intraventricular air and a fistula between the craniectomy site and ventricular system were identified by magnetic resonance imaging. Prompt repair of the dural defect using prosthetic dura mater resulted in immediate regression of the neurological signs and cerebral spinal fluid rhinorrhea. Magnetic resonance imaging repeated 8 weeks after surgery showed complete resolution of pneumocephalus.

CONCLUSIONS AND CLINICAL RELEVANCE

Tension pneumocephalus is an uncommon but life-threatening complication of craniectomy that requires urgent diagnosis and treatment.

Pneumocephalus secondary to a neck stab wound without neurologic injury in a 13-year-old girl

Pneumocephalus is usually caused by injury that damages the brain meninges and thus allows air to enter the intracranial cavity. Our intention was to establish the importance of considering a stab wound in the neck as a possible cause of traumatic pneumocephalus. The paper presents the case of a 13-year-old girl who was accidentally stabbed in the neck with a kitchen knife by her brother. She had no neurological deficit but had developed headaches. An examination showed cerebrospinal fluid leaking from the neck wound and a CT scan revealed the pneumocephalus. Following surgical treatment, the patient's clinical symptoms regressed. To our knowledge, this case is the first report of the manifestation of pneumocephalus as the result of a neck stab wound in a child; overall, there are only three reported cases of pneumocephalus caused by a neck stab wound.

Frontal sinus pneumocele. A case report

A pneumocele refers to an aerated sinus with either focal or generalized thinning of the bony sinus wall. Although the pathogenesis of a pneumocele is not yet known, it is presumed that increased intrasinusal pressure, due to a one-way valve between the nasal cavity and the affected sinus, is responsible for this condition. A 37-year-old man with frontal bossing, who underwent surgery for cosmetic reasons, is presented.

Pneumocephalus associated with ethmoidal sinus osteoma--case report

A 35-year-old female suffered sudden onset of severe headache upon blowing her nose. No rhinorrhea or signs of meningeal irritation were noted. Computed tomography (CT) with bone windows clearly delineated a bony mass in the right ethmoid sinus, extending into the orbit and intracranially. Conventional CT demonstrated multiple air bubbles in the cisterns and around the mass in the right frontal skull base, suggesting that the mass was associated with entry of the air bubbles into the cranial cavity. T1- and T2-weighted magnetic resonance (MR) imaging showed a low-signal lesion that appeared to be an osteoma but did not show any air bubbles. Through a wide bilateral frontal craniotomy, the cauliflower-like osteoma was found to be protruding intracranially through the skull base and the overlying dura mater. The osteoma was removed, and the dural defect was covered with a fascia graft. Histological examination confirmed that the lesion was an osteoma. The operative procedure resolved the problem of air entry. CT is superior to MR imaging for diagnosing pneumocephalus, by providing a better assessment of bony destruction and better detection of small amounts of intracranial air.

The "temporocele"

This article reports a case of spontaneous extracranial pneumatocele and introduces a new simple terminology for this clinical entity. A 10-year-old Saudi girl presented with left tympanoparietomastoid swelling. It was found to be fluctuant and full of air. On exploration, bony septae were found arising from the skull aponeurosis, the cranial boundary was elevated, and an ivory, cancellous bony swelling was over the root of the zygoma. No naked eye anatomic communication to the mastoid air cell was found. The mastoid pneumatization was within normal limits. All preoperative, operative, and postoperative investigations are presented. The authors introduce temporocele as a new term applied to this extracranial spontaneous pneumatocele.

Tension pneumocephalus--a rare complication of radiotherapy in nasopharyngeal carcinoma

A patient with nasopharyngeal carcinoma (NPC) treated by radiotherapy developed tension pneumocephalus due to a naso-cranial fistula. The fistula was due to a pathological fracture at the base of skull affected by bone necrosis. The clinical features, neuro-radiological and post-mortem findings are presented. This is the first case report of pneumocephalus in association with NPC. The brain showed florid subarachnoid and intraventricular air collection under tension, low grade meningitis, foreign body giant cell reaction in the arachnoid membrane and multifocal cerebral infarction. Late radiation necrosis was also found in the left temporal lobe. The cause of the tension pneumocephalus in relation to radiation bone necrosis and the possible role of pneumocephalus in producing the multifocal cerebral infarction are discussed. The more common radiation necrosis of brain is also discussed. The pathogenesis of the pneumocephalus in this patient is distinctly different from the more common causes such as head injury and surgery.

Pneumocephalus following treatment of esthesioneuroblastoma

The course of a patient with an olfactory neuroblastoma treated with conventional doses of chemotherapeutic agents and radiotherapy is presented. The patient survived 34 months after tumour necrosis with resultant pneumocephalus requiring surgical intervention.

Postmortem computed tomography in a diving fatality

Determination of the exact cause of death in diving casualties is usually difficult at autopsy. In such cases, formation of gas in various organs is sometimes supposed to be causative, and thus establishment of the exact distribution of gas is crucial. This is not possible by conventional autopsy techniques. In the head of a 20-year-old navy diver who died during a dive to a maximum depth of 43 m, it was possible to demonstrate the distribution of gas by cerebral computed tomography. Gas was also found by conventional X-ray examination of the right ventricle and by pulmonary angiography in the pulmonary arteries. It seems probable that the attempted resuscitation was unsuccessful because of ongoing decompression sickness.