Traumatic Subdural Pneumocephalus Causing Rise in Intracranial Pressure in the Early Phase of Head Trauma: Report of two Cases

Summary  This paper presents two unique cases of subdural tension pneumocephalus which has deteriorated in the early phase of head trauma. Subdural pneumocephalus accounts for about 25% of all intracranial pneumocephalus cases. In the literature subdural pneumocephalus is describes as a benign and spontaneously resolving condition. Contrary to the available literature and our experience in 1341 trauma cases in the past ten years of whom 76 had subdural pneumocephalus, both cases deteriorated in the early hours following head trauma due to an increase in subdural air volume which was evacuated by craniotomy.     

The relation of intracranial air to C.S.F. rhinorrhoea in the traumatic pneumocephalus (intracerebral and ventricular) (author's transl)

The relation of intracranial air to C.S.F. rhinorrhoea in our four cases, one intracerebral and the others intracerebral-ventricular pneumocephalus, were investigated on their clinical course, operative findings and RI-cisternographic findings. In the occurrence of the pneumocephalus, it seemed important for the damaged brain to herniate into the defect of the bone and dura matar. Clinically in the stage of an intracerebral pneumocephalus, the C.S.F. rhinorrhoea was not recognized as a rule. And next stage, the sudden effusions of C.S.F. appeared when the intracerebral pneumocephalus developed to the intracerebral-ventricular pneumocephalus.     

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.     

Intracerebral pneumocephalus following a head injury: case report

We report a case of intracerebral pneumocephalus following a head injury. This condition is relatively rare, and only 14 cases, including the present case, have been reported to data. A 40-year-old man fell from a 3rd floor window on June 29, 1999. The patient was admitted to the hospital. Plain skull X-ray films revealed a left basal skull fracture, and CT scan revealed a small contusion at the left frontobasal lobe. The patient was treated conservatively. On July 16, he underwent an MRI, and a small contusion was revealed at the left frontobasal lobe. In addition, the brain appeared to have herniated into the ethmoidal sinus. On July 22, the patient underwent a CT scan, and a intracerebral pneumocephalus was revealed in the left frontal lobe. On August 2, an MRI was performed, and intracerebral pneumocephalus in the left frontal lobe and herniation of the brain into the ethmoidal sinus were noted. In addition, intracerebral pneumocephalus had increased. The patient was admitted to our hospital. Clinotherapy was performed, but intracerebral pneumocephalus increased. On August 9, the patient underwent surgery to repair the skull base. During surgery, it was noted that the left frontal contusion had adhered to the edge of the lacerated dura around the bone defect of the ethmoidal sinus. Following surgery, no recurrence of pneumocephalus was noted. We conclude that once intracerebral air volume increases, early surgical repair should be carried out for intracerebral pneumocephalus. Meticulous MRI investigations of the lesion causing the intracerebral pneumocephalus should be conducted to select an appropriate operative procedure.     

Pneumocephalus secondary to tension pneumothorax associated with comminuted fracture of the thoracic spine

We present an unusual case of pneumocephalus secondary to a tension pneumothorax associated with fracture of the thoracic spine. Air from a pneumothorax entered the thoracic intraspinal compartment and the intracranial cavity through a comminuted fracture of the spine. The pneumocephalus and the pneumothorax resolved after aspiration of the intrathoracic air via an intercostal catheter. Diagnosis, therapeutic modalities, and potential complications of a pneumocephalus and of a communication between the thoracic cavity and the spinal dural space are discussed.     

Tension pneumocephalus after craniotomy in supine position

Tension pneumocephalus has been reported frequently after posterior fossa surgery, mostly in procedures done in the sitting position. Though uncommon, tension pneumocephalus is a life-threatening complication that requires urgent diagnosis and treatment. It is rare for this complication to occur after neurosurgical procedures done in the supine position. The authors report a case of an adult patient diagnosed with craniopharyngioma who developed tension pneumocephalus following craniotomy in the supine position.     

Tension pneumocephalus following external ventricular drain insertion

We report a rare case of the development of tension pneumocephalus after the placement of an external ventricular drain in a 4-year-old child with gross hydrocephalus and residual posterior fossa tumor. The child had developed hydrocephalus in the postoperative period after being operated for the posterior fossa tumor. The tension pneumocephalus resulted in delayed recovery in the child. The possible mechanism of the cause of pneumocephalus is discussed.     

Temporal Lobe Encephalocele in the Lateral Recess of the Sphenoid Sinus Presenting with Intraventricular Tension Pneumocephalus

A basal encephalocele often shows an insidious clinical course. Only two cases of temporal lobe encephalocele accompanied with tension pneumocephalus have previously been reported. In this paper, we describe a case of lateral sphenoid sinus encephalocele presenting with intraventricular tension pneumocephalus. A 54-year-old man was referred to our institution presenting with intraventricular tension pneumocephalus. He had undergone ventriculoperitoneal shunt placement for postmeningitis hydrocephalus 3 months before this admission. Precise imaging examinations detected evidence suggestive of a lateral sphenoidal sinus recess encephalocele. Endoscopic transnasal approach was performed for surgical repair of the encephalocele. The encephalocele was removed with subsequent repair of the bony defect. Histological examination showed that the encephalocele includes a part of the ventricular system. This indicates that air might enter directly into the ventricular system after rupture of the temporal lobe encephalocele. A lateral sphenoid sinus encephalocele would potentially cause intraventricular tension pneumocephalus, although pneumocephalus is an extremely unusual complication of this type of basal encephaloceles.     

Normobaric oxygen therapy strategies in the treatment of postcraniotomy pneumocephalus

OBJECT: Postsurgical pneumocephalus is an unavoidable sequela of craniotomy. Sufficiently large volumes of intracranial air can cause headaches, lethargy, and neurological deficits. Supplemental O(2) to increase the rate of absorption of intracranial air is a common but unsubstantiated neurosurgical practice. To the authors' knowledge, this is the first prospective study to examine the efficacy of this therapy and its effect on the rate of pneumocephalus absorption. METHODS: Thirteen patients with postoperative pneumocephalus that was estimated to be > or = 30 ml were alternately assigned to breathe 100% O(2) using a nonrebreather mask (treatment group) or to breathe room air (control group) for 24 hours. Head computed tomography (CT) scans without contrast enhancement were obtained at the beginning and end of treatment or control therapy. A neuroradiologist blinded to the type of treatment used software to calculate the 3D volume of the pneumocephalus from the CT scans. The percentage of pneumocephalus absorption was calculated for each study participant. RESULTS: There was no statistically significant difference between the treatment and control groups regarding the mean initial pneumocephalus volume or time interval between CT scans. There was a significant difference (p = 0.009) between the mean rate of pneumocephalus volume reduction in the treatment (65%) and control groups (31%) per 24 hours. No patient suffered adverse effects related to treatment. CONCLUSIONS: Administration of postsurgical supplemental O(2) through a nonrebreather mask significantly increases the absorption rate of postcraniotomy pneumocephalus as compared with breathing room air.     

Spontaneous otogenic pneumocephalus

Otogenic pneumocephalus is uncommon. Typical causes include trauma, tumor, infection, and nasosinusal or mastoid surgery but spontaneous otogenic pneumocephalus is very exceptional. We report a case of spontaneous otogenic pneumocephalus located in the left temporal lobe revealed by sudden onset aphasia. The temporal pneumatocele was cured through an epidural subtemporal approach with needle puncture of the aeroma and duroplasty. Two years after surgery, no recurrence was observed and the patient remained symptom free.     

Endonasal Ethmoidectomy and Bifrontal Craniotomy with Craniofacial Approach for Resection of Frontoethmoidal Osteoma Causing Tension Pneumocephalus

Tension pneumocephalus is an unusual, potentially life-threatening complication of frontal fossa tumors. We present an uncommon case of a frontoethmoidal osteoma causing a tension pneumocephalus and neurological deterioration prompting a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach for resection. A 68-year-old man presented with a 1-week history of worsening headache, slowness of speech, and increasing confusion. Standard computed tomography scan revealed a marked tension pneumocephalus with ventricular air and 1-cm midline shift to the right. Further studies showed a calcified left ethmoid mass and a left anterior cranial-base defect. A team composed of neurosurgery and otolaryngology performed a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach to resect a large frontoethmoid bony tumor. No abscess or mucocele was identified. The skull base defect was repaired with the aid of a transnasal endoscopy, a titanium mesh, and a pedunculated pericranial flap. Postoperatively, the pneumocephalus and the patient's symptoms completely resolved. Pathology was consistent with a benign osteoma. This is an uncommon case of a frontoethmoidal osteoma associated with tension pneumocephalus. Recognition of this entity and timely diagnosis and treatment, consisting of an endonasal ethmoidectomy and a bifrontal craniotomy with craniofacial approach, may prevent potential life-threatening complications.     

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.     

Pneumocéphalie compressive après traitement chirurgical d’un hématome sous-dural chronique bilatéral : une complication banale et sérieuse

The occurrence of postoperative pneumocephalus is a common event and is often trivial. When the intracranial air volume is significant, it creates intracranial hypertension causing tension pneumocephalus. This case report describes the occurrence of tension pneumocephalus after surgical drainage of bilateral chronic subdural hematoma. The pneumocephalus was responsible for severe postoperative neurological deterioration. The attending physicians should be aware of the possibility of occurrence of such complication. Treatment and prevention of pneumocephalus should also be well known by the medical staff.     

Spontaneous epidural pneumocephalus

A 20-year-old male presented with an extremely rare spontaneous epidural pneumocephalus which was successfully treated by a single neurosurgical intervention. The patient had a habit of nose blowing and a 1-year history of progressive headache and nausea. Cranial computed tomography (CT) revealed a 2 x 7 cm right temporo-occipital epidural pneumocephalus with extensive hyperpneumatization of the mastoid cells. Right temporo-occipital craniotomy with a right superficial temporal artery and vein flap repair resulted in radiographic resolution of the pneumocephalus, and he remained neurologically free of symptoms at 1-year follow-up examination. Early identification and monitoring of symptomatic pneumocephalus followed by decompression and prevention of infection via closure of the bone defect can avoid possible serious consequences. The underlying mechanisms may involve a congenital petrous bone defect and a ball-valve effect due to excessive nose blowing in our case.     

Symptomatic Pneumocephalus after Transsphenoidal Surgery

Background

Symptomatic pneumocephalus after transsphenoidal surgery, though reported, is a rare phenomenon. We report three cases of pneumocephalus in a series of 300 transsphenoidal operations for sellar/suprasellar mass lesions done over the past 12 years.

Methods and Results

Three cases of symptomatic pneumocephalus occurring after transsphenoidal surgery are presented to illustrate the causative factors, methods of prevention, and management. In case 1, an intraoperative cerebrospinal fluid (CSF) leak occurred and drainage of CSF through a lumbar subarachnoid drain resulted in pneumocephalus, in spite of repair of the sellar floor. In case 2, partial excision of tumor and subsequent reduction of intracranial pressure due to a ventriculoperitoneal (VP) shunt led to pneumocephalus. In case 3, radiotherapy-induced shrinkage of a partially excised tumor resulted in pneumocephalus. The sellar floor had not been repaired in cases 2 and 3 as there was no intraoperative CSF leak and only a partial excision had been done. Conservative management failed in the two patients in whom it was tried. Repair of the sella and sphenoid sinus had to be done in all three cases.

Conclusions

Repair of the sellar floor should be done after a transsphenoidal approach in all cases, even when no intraoperative leak has been identified and only a partial excision of tumor has been done. Once pneumocephalus has occurred, the sellar floor and sphenoid sinus should be repaired early before reducing the intracranial pressure (ICP) by tapping ventricular air and draining or diverting CSF.     

Pneumocephalus: effects of patient position on the incidence and location of aerocele after posterior fossa and upper cervical cord surgery

The incidence of pneumocephalus and factors contributing to its occurrence were studied retrospectively in 100 consecutive patients who underwent posterior fossa or cervical cord surgery in the sitting, park-bench, and prone positions. Supine skull x-ray films taken immediately postoperatively were used to determine the presence of intracranial air. Surgery in the sitting position uniformly resulted in pneumocephalus (32/32 patients). Pneumocephalus also occurred frequently among patients in the park-bench (29/40) and prone positions (16/28). Intraventricular air occurred more frequently when patients were in the sitting position (25/32) than in the two other surgical positions (3/29 and 4/16, respectively, P less than 0.001). The high incidence of pneumocephalus and of intraventricular air that occurred when patients were in the sitting position is attributed to the large amount of cerebrospinal fluid drained due to gravitational effect. When surgical position is considered one of the contributing factors, only positions significantly affected the frequencies of pneumocephalus and intraventricular air accumulation. None of the 77 patients with pneumocephalus suffered neurologic change related to the presence of intracranial air. We conclude the following: pneumocephalus commonly occurs after posterior fossa or cervical cord surgeries, particularly when the surgery is performed in the sitting position; neurologic change caused by pneumocephalus is a rare complication after posterior fossa craniotomy; when a patient with coexisting hydrocephalus undergoes surgery, if the patient is in the sitting position, there is an increased risk of trapping a large amount of intracranial air.     

Cerebrospinal fluid rhinorrhea and intraventricular pneumocephalus due to intermittent shunt obstruction

Cerebrospinal fluid rhinorrhea and intraventricular pneumocephalus occurred in an adolescent with aqueduct stenosis whose ventriculoperitoneal shunt occluded repeatedly due to a faulty on-off control. The possible mechanisms are discussed, the urgency of treatment is stressed, and the risk of pneumocephalus when a shunt is used to treat cerebrospinal fluid rhinorrhea is pointed out.     

Case of postoperative subdural tension pneumocephalus

In this paper, a case with subdural tension pneumocephalus secondary to bifrontal craniotomy and VP shunt for ruptured Acom aneurysm is reported. In this patient, the mechanisms for entry of air into the subdural space and producing mass effect (Tension pneumocephalus) seem to be one way valve mechanism and negative pressure due to excess of CSF drainage owing to shunting system. Only 29 reported cases of tension pneumocephalus following surgery were found in an extensive review of the literature. We discussed about the clinical symptoms and signs, therapy, and especially about the mechanisms leading to this condition, and prevention for it.     

Pneumocephalus and Pneumorrhachis after Spinal Surgery: Case Report and Review of the Literature

Trauma is a common cause of pneumocephalus, or air in the cranial cavity, and of pneumorrhachis, or the presence of intraspinal air. After spinal surgery, occurrence of pneumocephalus, especially with pneumorrhachis, is extremely rare. We report the case of a patient who developed pneumocephalus and pneumorrhachis after lumbar disc surgery and pedicle screw fixation. There was no cerebrospinal fluid leakage during surgery. On postoperative day 1, the patient complained of headache, nausea, and dizziness. Brain and lumbar computed tomography scans revealed pneumocephalus and pneumorrhachis. With conservative treatment, the patient''s complaints resolved within 10 days.     

Subdural and intraventricular traumatic tension pneumocephalus: case report.

Simple pneumocephalus most frequently arises as a complication of a head injury in which a compound basal skull fracture with tearing of the meninges allows entry of air into the cranial cavity. It can also follow a neurosurgical operation. Tension traumatic pneumocephalus with intraventricular extension is an extremely rare, potentially lethal condition that requires prompt diagnosis and treatment. We report the case of subdural and intraventricular accidental tension pneumocephalus occurring in a 26-year-old man as a result of skull fracture. This case is combined with rhinorrhea and meningitis that suggest some difficulties to treat. The operative procedure associated with medical treatment was performed and a good result was obtained.