- Department of Anesthesia/SICU, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Pharmacy, Hamad Medical Corporation, Doha, Qatar
Department of Anesthesia/SICU, Hamad Medical Corporation, Doha, Qatar
DOI:10.4103/2152-7806.65185© 2010 Shaikh N. 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: Shaikh N, Masood I, Hanssens Y, André Louon, Hafiz A. Tension pneumocephalus as complication of burr-hole drainage of chronic subdural hematoma: A case report. Surg Neurol Int 06-Jul-2010;1:27
How to cite this URL: Shaikh N, Masood I, Hanssens Y, André Louon, Hafiz A. Tension pneumocephalus as complication of burr-hole drainage of chronic subdural hematoma: A case report. Surg Neurol Int 06-Jul-2010;1:27. Available from: http://sni.wpengine.com/surgicalint_articles/tension-pneumocephalus-as-complication-of-burr-hole-drainage-of-chronic-subdural-hematoma-a-case-report/
Background:Pneumocephalus is the presence of air in the cranial cavity. When this intracranial air causes increased intracranial pressure and leads to neurological deterioration, it is known as tension pneumocephalus (TP). TP can be a major life-threatening postoperative complication, especially after evacuation of chronic subdural hematoma. We report a case of TP after evacuation of chronic subdural hematoma and review the literature.
Case Description:A 70-year-old man developed right-sided weakness after being admitted with minor head trauma a few weeks earlier. He was found to have a chronic subdural hematoma and underwent burr-hole evacuation. On day 3, he suddenly deteriorated and needed intubation and ventilation. Computerized tomography (CT) of the brain showed typical Mount Fuji’s sign due to TP. Immediately, 20-30 mL of air was aspirated from the intracranial fossa, and a catheter drain was inserted. The patient became fully awake after few hours and was extubated successfully. The drain was removed on day 5, and he was transferred to the ward before being discharged home.
Conclusion:TP after evacuation of a chronic subdural hematoma is a neurosurgical emergency and needs immediate resuscitation and therapy; hence it is of vital importance that all acute-care physicians, intensivists and neurosurgeons be aware of this clinical emergency.
Keywords: Catheter drain insertion, Mount Fuji sign, neurological deterioration, pneumocephalus, tension pneumocephalus
Presence of air in the cranial cavity is termed as pneumocephalus; and when this benign air causes pressure effect, it is called tension pneumocephalus (TP). It is manifested by neurological deterioration. TP is a rare neurosurgical emergency; if not diagnosed early and treated properly, it can be fatal. As little as 25 mL of air can cause TP.[
It is of vital importance that all acute-care physicians, intensivists and neurosurgeons be aware of this clinical entity and the need to detect it early and manage properly. We report a case of TP after evacuation of CSDH and review the literature.
A 70-year-old man developed right-sided weakness of 3 days’ duration. He was admitted 1 month earlier with minor head trauma. The patient’s medical history included diabetes mellitus and hypertension, both controlled with medications. Computerized tomography (CT) of the head showed acute on CSDH. The same day, he underwent burr-hole evacuation of the hematoma and was postoperatively transferred to the surgical intensive care unit (SICU). He was awake and hemodynamically stable, and a follow-up CT brain evidenced pneumocephaly. On day 3, the patient became unresponsive, flexing response to deep pain, and became bradyapneic. He needed intubation and ventilation. An emergency CT evidenced TP [
Pneumocephalus is common after intracranial surgery and trauma; it usually gets absorbed without any clinical manifestations. Rarely, due to various etiological factors, this benign air will get trapped into the cranial cavity leading to an increase in the intracranial pressure and causing neurological deterioration. This clinical entity is termed tension pneumocephalus (TP). TP is a rare but life-threatening postoperative complication of the evacuation of CSDH.[
Epidemiology and risk factors
The main risk factors are (i) replacement of chronic subdural hematoma with oxygen,[
TP occurs when the volume of cerebrospinal fluid (CSF) decreases during surgery, but it can also occur due to other reasons. Air will rush into the brain spaces via bony or dural defects to fill, and get collected in, the negative pressure space created by the loss of CSF. When the CSF volume is restored, but volume of air remains the same, it leads to air trapping and TP.[
A CT scan of the brain is the most sensitive method and a gold standard for diagnosis of TP. CT imaging is also helpful in differentiating TP from benign forms. The CT will show the typical ‘Mount Fuji’, sign – bilateral hypo-attenuating collection causing compression and separation of the frontal lobes and widening of interhemispheric space between the tips of the frontal lobe, giving a picture of the silhouette of Mount Fuji [
Criteria for the diagnosis of TP are (a) typical CT brain findings, (b) neurological deterioration, (c) hissing sound of escape of air and (d) immediate improvement in the neurological status upon aspiration of air.[
TP is a neurosurgical emergency, and the patient should immediately be started on a higher concentration of inspired oxygen and maintained in supine position. If the Glasgow coma score (GCS) decreases below 8, endotracheal intubation is needed. Simultaneously, one can reopen the frontal burr hole to release the air; or a new bedside burr hole can be made for aspiration of the air and insertion of a catheter drain to lessen the risk of infection; or a twisted-drill craniotomy can be performed with insertion of a drain.[
In patients with evacuation of CSDH, brain tissues will not expand immediately to fill the space created. To avoid development of TP, flushing of subdural space with saline, placement of patient on 100% oxygen before closing the wound with head elevation in supine position, and insertion of close-system drain should be considered. The drain can be kept for a maximum of 48 hours to minimize the chance of infection, venting the residual intracranial air, and the patient should be nursed in a supine position.[
Sharma et al.[
There are advantages and disadvantages [
We believe that, keeping the drain helps the patient, and disadvantages of the drain can be prevented by meticulous precautions during insertion, following strict aseptic technique and removal of the drain as early as possible.
Rarely, a smaller amount of air in the extra-axial space around the brainstem after evacuation of CSDH in supine position can cause vital center compression, as reported by Parkash et al.[
Prevention of TP begins as soon as the patient gets admitted to the hospital with the primary pathology and includes obtaining consent for the surgical procedure, educating the patient and family about the risk factors of TP and applying all possible measures to avoid them. Intraoperative saline flushing, avoiding nitrous oxide, supine position and a closed-system drain will all help in preventing TP.[
TP after evacuation of the chronic subdural hematoma is a neurosurgical emergency. Closed-system drains will significantly prevent TP. TP needs immediate resuscitation and therapy; hence it is of vital importance that all acute-care physicians, intensivists and neurosurgeons be aware of this clinical emergency.
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