- Neurosurgical Department, Yalta City Hospital, Yalta, Crimea, Ukraine
Volodymyr O. Solomiichuk
Neurosurgical Department, Yalta City Hospital, Yalta, Crimea, Ukraine
DOI:10.4103/2152-7806.109537Copyright: © 2013 Solomiichuk VO This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 25-Mar-2013;4:37
How to cite this URL: Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 25-Mar-2013;4:37. Available from: http://sni.wpengine.com/surgicalint_articles/posttraumatic-delayed-subdural-tension-pneumocephalus/
Background:Pneumocephalus is a complication of head injury in 3.9-9.7% of the cases, it also appears after supratentorial craniotomy in 100% of cases. The accumulation of intracranial air can be acute (
Case description:We represent a clinical case of a 75-year-old male patient with open penetrating head injury, complicated by tension pneumocephalus on the fifth day after trauma and underwent urgent surgical correction. Operation performed: Burr-hole placement in the right frontal region, evacuation of tension pneumocephalus.
Conclusion:Tension pneumocephalus is a life-threatening neurosurgical emergency case, which needs to undergo immediate surgical or conservative treatment.
Keywords: Computed tomography scan, cerebrospinal fluid leak, craniofacial trauma, head injury, tension pneumocephalus
Pneumocephalus, also known as intracerebral aerocele or pneumatocele, is a collection of air in the cranial cavity.[
The first description of pneumocephalus was provided by Thomas in 1866.[
Mechanism of pneumocephalus development was described by two theories: (1) Dandy theory of “ball valve”[
Pneumocephalus can be caused by:
Trauma (basal skull fractures, paranasal sinuses fractures,[ Neurosurgical operations (twist-drill evacuation of chronic subdural hematomas;[ ENT operations (paranasal sinuses surgery; nasal septum resection; nasal polypectomy) Lumbar punctures[ Barotrauma Tumors CNS infections caused by gas-producing microorganisms Nitrous oxide Congenital skull and tegmen tympani defects Spinal anesthesia Positive pressure ventilation Hyperbaric oxygen therapy Spontaneous Scuba diving
Trauma (basal skull fractures, paranasal sinuses fractures,[
Neurosurgical operations (twist-drill evacuation of chronic subdural hematomas;[
ENT operations (paranasal sinuses surgery; nasal septum resection; nasal polypectomy)
CNS infections caused by gas-producing microorganisms
Congenital skull and tegmen tympani defects
Positive pressure ventilation
Hyperbaric oxygen therapy
Clinical presentation of tension pneumocephalus may include headache, generalized seizures, agitation, delirium, reflex abnormalities, otherwise altered level of consciousness, pupillary changes, and frontal lobe syndrome. Tension pneumocephalus localized in the posterior cranial fossa can cause clinical signs of brainstem dislocation,[
Computed tomography (CT) is a golden standard for tension pneumocephalus diagnostics. A bilateral subdural hypoattenuation (Hounsfield coefficient – 1000) collections, causing compression and separation of frontal lobes (widened interhemispheric fissure), with separated frontal lobes tips on CT scans were described as “Mount Fuji sign” by Ishiwata, et al. as pathognomonic sign of tension pneumocephalus.[
Tension pneumocephalus treatment includes a complex of manipulations directed to removing of intracranial air mass-effect, adequate skull base defects closure, and secondary posttraumatic meningitis prophylaxis.
Initial treatment is usually conservative, including bed rest in an upright position, high concentration oxygen, avoidance of maneuvers that might increase intrasinus pressure (such as nose-blowing or valsalva maneuver) and antibiotics if there is evidence of meningism. Surgical treatment is indicated when there is recurrent pneumocephalus or signs of increasing intracranial pressure suggesting development of tension pneumocephalus.[
A 75-year-old right-handed male with trauma signs on his head (right-sided paraorbital hematoma and a wound in his frontal region) was admitted to Yalta City Hospital after he fell down at the entrance of his house. He lost consciousness for about 2 minutes. On admission, he was Glasgow coma scale (GCS) 15 with right-sided exophthalmos up to 4 mm. He complained of headache and diplopia while looking to the right.
Neurologically: Limitation of the right eye abduction, eyeballs weak of convergence.
CT showed frontal sinus fracture with extension to the right orbital roof and minimal pneumocephalus [
On the fifth day after admission to neurosurgical department, he was noticed to be deteriorating neurologically. His GCS dropped to 12, meningeal signs were found and he became bradyapneic. It was a “Mount Fuji sign” on the cranial CT scans [
Under general anesthesia, a burr-hole was placed in the right frontal region and subdural space was irrigated with normal saline and admitted to the intensive care unit (ICU).
Next day after the surgical treatment, he improved and became awake. He was successfully weaned of the ventilator and admitted to the neurosurgical department. Subdural drain was removed.
On the brain CT scans there was a minimal residual air [
Patient underwent a conservative treatment and observation. On the sixth day after the operation, an episode of hyperthermia up to 38°C developed.
On the 11th day, nasal liquorrhea resumed. On the background of the therapy, a sustained clinical improvement was achieved.
Patient refused to undergo proposed surgical intervention, aimed at dura defect closure in the posterior wall of the frontal sinus. On the 22nd day after hospitalization, on the urge of family members, patient was transferred to Kyiv Municipal Clinical Emergency Hospital. On the second day after transfer, nasal liquorrhea resumed. Watertight dura closure and cranioplasty was performed. The postoperative period was uneventful and CSF was without signs of inflammation. In 12 days after surgery, patient was discharged. At his 14 month follow-up, he has no neurological deficit and no signs of liquorrhea and meningitis.
Tension pneumocephalus is a life-threatening neurosurgical emergency case, which needs to undergo immediate surgical or conservative treatment.
Even minor air collection in the cranial cavity has a risk of transformation into tension pneumocephalus in case of valve mechanism development.
Considering existence of tension pneumocephalus mentioned cases and development in the late postoperative or/and posttraumatic period, these patients should be subject for long-term follow-up after discharge from hospital.[
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