Pneumocephalus in subthalamic deep brain stimulation for Parkinson's disease: a comparison of two different surgical techniques considering factors conditioning brain shift and target precision

BACKGROUND

Precise placement of electrodes in deep brain stimulation (DBS) may be influenced by brain shift caused by cerebrospinal fluid leaking or air inflow. We compared accuracy and treatment outcomes between a standard technique and one aiming at reducing brain shift.

METHODS

We retrospectively reviewed 46 patients (92 targets) treated with bilateral subthalamic-DBS for Parkinson's disease. The patients were divided into two groups: group A surgery was performed in supine position with standard burr hole, dural opening, fibrin glue and gelfoam plugging. Group B patients were operated in a semi-sitting position with direct dural puncture to reduce CSF loss. We analysed target deviation on head CT performed immediately after surgery and at 1 month merged with preoperative MRI planning. We recorded pneumocephalus volume, brain atrophy and target correction by intraoperative neurophysiology (ION).

RESULTS

In group A, the mean pneumocephalus volume was 10.55 cm³, mean brain volume 1116 cm³, mean target deviation 1.09 mm and ION corrected 70% of targets. In group B, mean pneumocephalus was 7.60 cm³ (p = 0.3048), mean brain volume 1132 cm³ (p = 0.6526), mean target deviation 0.64 mm (p = 0.0074) and ION corrected 50% of targets (p = 0.4886). Most leads' deviations realigned to the planned target after pneumocephalus reabsorbtion suggesting a deviation caused by displacement of anatomical structures due to brain shift. Definitive lead position was always decided with ION.

CONCLUSIONS

The modified DBS technique significantly reduced errors of electrode placement, though such difference was clinically irrelevant. ION corrected a high amount of trajectories in both groups (70% vs 50%). The choice of either strategy is acceptable.

Pneumocephalus following fluoroscopy-guided lumbar epidural injection in elderly patients: two cases report and a review of Korean literatures - Two cases report

Background

Pneumocephalus can originate from accidental dural puncture while performing epidural block using the loss-of-resistance (LOR) technique with an air-filled syringe.

Case

We present two cases of pneumocephalus after lumbar epidural block under fluoroscopy for pain control in elderly patients.

Conclusions

Lumbar epidural block should be performed under fluoroscopic guidance in elderly patients with severe lesions. The physician should be aware of the increased possibility of a dural puncture occurring due to anatomical changes in older patients. The use of saline is recommended for the LOR technique. A contrast injection should be used together with the LOR technique to locate the epidural space. If a dural puncture occur, the patient should be carefully monitored to determine whether pneumocephalus has developed.

Unilateral blindness following superior laryngeal nerve block for awake tracheal intubation in a case of posterior cervical spine surgery

Background:

Superior laryngeal nerve block (SUPLANEB) is a popular airway anesthesia technique utilized for successful awake endotracheal intubation in patients with significant cervical spine instability. If not performed by an expert, it carries the risk of general/neurologic complications that are typically minimal/transient. However, permanent blindness and/or upper cranial nerve neuropathies may occur. Here, we describe a case in which a young patient underwent an atlantoaxial fusion for a C2 nonunion (e.g., following a fracture) complicated by unilateral blindness due to a SUPLANEB.

Case Description:

A 25-year-old neurologically intact male underwent a C1-C2 posterior arthrodesis to address a nonunion of a C2 fracture. To perform the awake nasotracheal intubation, a SUPLANEB was performed using a video laryngoscope. Although the operation was uneventful, postoperatively, the patient reported left visual loss accompanied by left-sided facial numbness and hearing loss. On examination of the left eye, the anterior segment and fundus examinations were normal, but the OCT (optical coherence tomography) and retinal angiography demonstrated left-sided postischemic retinal edema with permeability of the intraocular vessels. Although the cranio-orbital computed tomography scan showed only mild pneumocephalus, the CT angiogram scan revealed abnormal air in the left carotid sheath accompanied by diffuse subcutaneous emphysema. Further, brain and orbital magnetic resonance imaging scans were normal. The patient was treated with pure oxygen, systemic steroid therapy, and nimodipine. The pneumocephalus and subcutaneous emphysema resolved on day 3. At 2 months follow-up, the patient remained blind on the left side, but had no further neurological deficits.

Conclusion:

Blindness and upper cranial nerves neuropathies should be considered as potential complications of SUPLANEB. Notably, these deficits were not directly related to the operative positioning or neurosurgical spinal procedure.

Post-operative intracranial gas migration with optic nerve infiltration and atrophy following retinal detachment repair

Purpose

To report a patient with post-operative gas migration into the optic nerve and lateral ventricles after retinal detachment repair.

Observations

A 78-year-old pseudophakic man developed a temporal visual field cut in his non-operative, right eye 3 weeks after repair of a recurrent, shallow, macula-involving retinal detachment with perfluoropropane intraocular gas in the left eye. Visual acuity in the right eye measured 20/40, and static perimetry demonstrated temporal visual field loss that respected the vertical midline. Dilated fundus examination of the right eye was unrevealing for any retinal cause, raising suspicion for an intracranial etiology. An urgent CT scan of the brain demonstrated gas in all segments of the left optic nerve and lateral ventricles, consistent with intracranial gas migration along the optic nerve. Given the absence of systemic neurologic symptoms, cautious observation was advised on consultation with neuroradiology and neurosurgery, and follow-up CT scan 1 week later showed resolution of the intracranial gas. By 10-weeks post-operatively, vision returned to 20/20 in the right eye with persistent temporal field loss, and the left eye was hand motions (20/70 pre-operatively) with evidence of optic nerve atrophy and severe cupping.

Conclusions

Intracranial gas migration is a rare complication of retinaldetachment repair with intraocular gas and may occur in the setting of structural defects of the optic nerve and high post-operative intraocular pressure. Clinicians should be alert to this rare but serious complication, which can cause neurologic symptoms and result in vision loss in both the operative and non-operative eyes.

Spontaneous cerebrospinal fluid otorrhea and pneumocephalus on the contralateral side of the previous cranial surgery

Background

Cerebrospinal fluid (CSF) leaks and pneumocephalus commonly occur due to head trauma or surgical procedures. Spontaneous CSF (sCSF) leaks, however, occur without any clear etiology and are relatively uncommon.

Case Description

An 84-year-old woman presented with the right-sided otorrhea. The patient had a history of a ventriculoperitoneal shunt placement following a subarachnoid hemorrhage treated by clip ligation of a left-sided ruptured cerebral aneurysm 7 years before presentation, with shunt catheter ligation after evidence of intraventricular pneumocephalus 6 years before presentation. At admission, computed tomography (CT) imaging of the head showed enlargement of the lateral ventricles, a right mastoid fluid collection, and a defect of the superior wall of the right petrous bone. We performed a right temporal craniotomy for the repair of the CSF leak. Intraoperatively, it was noted that temporal lobe parenchyma herniated into the mastoid air cells through lacerated dura and a partially defective tegmen mastoideum. The leak point was successfully obliterated with a pericranial graft and reinforced by a collagen sheet and fibrin glue. There was no recurrence of otorrhea postoperatively.

Conclusion

This report presents a very unique case of a patient with a CSF leak and pneumocephalus occurring on the contralateral side of a previous cranial surgery. We accurately identified the defect site with CT imaging and repaired the CSF leak by temporal craniotomy. Awareness of the mechanisms by which sCSF leaks can be caused by aberrant arachnoid granulations is imperative for neurosurgeons.

Pulsatile tinnitus caused by pneumocephalus after Janneta surgery

Pulsatile tinnitus of nonvascular origin is rare. We herein present a case of pulsatile tinnitus complicated with Jannetta surgery due to a communication created between the drilled mastoid cells and epidural space. She was successfully cured by otological surgery where the mastoid tip was packed with bone cement. A 68-year-old woman was referred to the previous hospital with complaints of right autophony, aural fullness, hyperacusis to her footsteps, and pulsatile tinnitus for the past three years. She had received Jannetta surgery for right hemifacial spasm seven years before. The computed tomography (CT) of the right temporal bone showed bony dehiscence between the mastoid cells and posterior cranial fossa. She underwent otological surgery to obliterate the tip of the mastoid cavity with artificial bone cement (BIOPEX^Ⓡ) under general anesthesia. Her annoying aural symptoms were immediately abolished and she has been free from symptoms at ten months after surgery. It is critical to ensure the closure of any communication created between the middle ear and epidural space during surgeries in order to prevent the occurrence of pulsatile tinnitus.

Pneumocephalus and Chemical Meningitis after Inadvertent Dural Puncture during Lumbar Epidural Injection

Inadvertent dural puncture (IDP) is one of the complications of lumbar epidural steroid injections (ESIs). We report a case in which pneumocephalus and chemical meningitis developed at the same time after an IDP during a lumbar interlaminar ESI. A 60-year-old woman presented to the emergency room with thunderclap headache and febrile sensation 3 hours after receiving a lumbar interlaminar ESI. Brain computed tomography (CT) scan showed multiple small foci of air within the subarachnoid space and ventricle. After the admission, the patient was afebrile and reported mild improvement of headache with analgesics. However, 2 days after the admission, headache worsened and fever recurred. Follow-up brain CT scan revealed resolution of the pneumocephalus. A diagnostic lumbar puncture for cerebrospinal fluid (CSF) examination revealed the findings suggestive of aseptic (chemical) meningitis rather than bacterial meningitis. With symptomatic treatment, headache improved and there was no fever after 48 hours. No bacteria, Mycobacterium, or fungi grew in the CSF for 7 days. This case shows an IDP during a lumbar ESI can cause pneumocephalus and chemical meningitis at the same time and efforts should be made to reduce the risk of IDP during lumbar ESIs.

From Toothpick to Intraparenychmal Otogenic Pneumocephalus: A Case Report

BACKGROUND

Intracranial pneumocephalus, the accumulation of air, occurs most frequently from trauma, tumor, cranial surgeries, or infection. Intraparenchymal otogenic pneumocephalus is a rare but well-documented development. We describe a patient who developed pneumocephalus in the context of eardrum perforation secondary to toothpick use for ear wax.

CASE DESCRIPTION

An 86-year-old female presented to the emergency room with a 1-day history of dysarthria and a few days of cough and sneezing. History revealed she had recently been advised to avoid Q-Tips to clean her ears and instead was using toothpicks. She denied otalgia or otorrhea and had no signs of infection near the ear. On otoscopic examination, the right tympanic membrane was perforated. On head computed tomography, she was found to have a large right temporal pneumocephalus extending from the petrous bone. Magnetic resonance imaging of the brain revealed a defect in the right tegmen. She was started on empiric antibiotics and subsequently taken to the operating room for craniotomy and repair of bony and dural defects.

CONCLUSIONS

Otogenic pneumocephalus is a rare occurrence. This is the first reported case of pneumocephalus related to self-induced middle ear trauma with a toothpick that ultimately required craniotomy for repair.

Oxygen Embolism and Pneumocephalus After Hydrogen Peroxide Application During Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Case Report and Literature Review

BACKGROUND

Hydrogen peroxide (H₂O₂) solution is commonly used to irrigate wounds because of its hemostatic and antiseptic properties. Previous studies suggest that H₂O₂ can result in toxicity to keratinocytes and fibroblasts, but complications after H₂O₂ application, including oxygen embolism, which is one of the most severe, have rarely been reported.

CASE DESCRIPTION

A 40-year-old woman was diagnosed with L4-5 lumbar spinal stenosis and subsequently underwent minimally invasive transforaminal lumbar interbody fusion treatment at another hospital. Hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occurred immediately after H₂O₂ irrigation. After the operation, she was able to be extubated but remained comatose. Postoperative computed tomography scan revealed intracranial air trapping in the right frontal lobe and multiple cerebral infarction foci.

CONCLUSIONS

When using a knee-prone surgical position or in cases of dural laceration, the application of undiluted H₂O₂ solution should be avoided, especially in a surgical wound within a closed cavity. When hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occur immediately after H₂O₂ irrigation, oxygen embolism should be strongly suspected.

Symptomatic Pneumocephalus as a Complication of Lumbar Epidural Anaesthesia

Introduction

Lumbar epidural anaesthesia is a commonly used technique for analgesia during labour. One of the rare complications of this technique is pneumocephalus.

Case description

We report the case of a 35-year-old female admitted to the Emergency Department with severe headache associated with fast head movements. Five days previously she had a eutocic delivery and lumbar epidural anaesthesia was performed. A brain computed tomography (CT) scan showed pneumocephalus and she was admitted to the hospital ward. A brain CT scan on the fourth day of hospitalization showed resolution of ventricular pneumocephalus.

Discussion

The most frequently occurring symptom with pneumocephalus is headache associated with fast brain motion resulting from air injection and meningeal irritation. When there is clinical suspicion of pneumocephalus, a brain CT scan should be performed for the diagnosis.

LEARNING POINTS

Pneumocephalus is the presence of air in the intracranial cavity and its development after spinal or epidural anaesthesia is extremely infrequent.Headache that occurs in the setting of lumbar epidural anaesthesia should not be labelled as post-dural puncture headache.The suspicion of pneumocephalus, based on the characteristics of the headache, should be maintained to obtain an emergent brain CT scan.

Disseminated pneumocephalus secondary to air compressor injury

We report an unusual case of a young male patient who presented with severe pain and swelling of his left eyelid following an air compressor tip accident. He suffered extensive facial edema accompanied by deep tissue emphysema and an elevated intraocular pressure. On noncontrast CT scan, air was detected in the intraconal and extraconal orbital compartments, and intracranially within the subarachnoid spaces as well as in the suprasellar and perimesencephalic cisterns. There were no detectable fractures. We presume that by perforating the orbital septum, Tenon's capsule, and the optic nerve sheath, air had managed to penetrate the cranium through the optic nerve subarachnoid space and into the intracranial subarachnoid space.

Significance of intracranial gas on post-mortem computed tomography in traumatic cases in the context of medico-legal opinions

The detection of intracranial gas (ICG) in people who died due to trauma became possible once postmortem computed tomography (PMCT) became available in addition to traditional post-mortem examinations. The aim of this study was to determine the importance of ICG in the context of medico-legal opinions. We assessed 159 cases of trauma-induced death. Cadavers with pronounced signs of decomposition, open skull fractures, and after neurosurgical operations were excluded. Both PMCT findings and data from autopsy reports were analyzed. ICG was found in 38.99% (n = 62) of the cadavers, 96.77% (n = 60) of which presented with pneumocephalus (PNC) and 40.23% (n = 25) with intravascular gas (IVG). There was a strong correlation between ICG and skull fractures/brain injuries, as well as chest injuries, especially lung injuries. In 13 cases, ICG presented without skull fractures; three of these cases died as a result of stab and incised wounds to the neck and chest. The mean time between trauma and death was significantly longer in the non-ICG group than the ICG group at 2.94 days (0–48 days) and 0.01 day (0–1 day), respectively (p < 0.0001). The presence of ICG is a result of severe neck and chest injuries, including stab and incised wounds. The victims die in a very short amount of time after suffering trauma resulting in ICG. The ability to demonstrate ICG on PMCT scans can be of significance in forming medico-legal opinions.

Extensive Pneumocephalus Caused by Multidrug-Resistant Klebsiella pneumoniae

Pneumocephalus is a life-threatening event associated with different infectious diseases and trauma. Klebsiella pneumoniae is a gas-forming organism that can cause pneumocephalus. A woman aged 56 years presented with a history of septic shock and community-acquired pneumonia. She was supported by mechanical ventilation in intensive care unit. Multidrug-resistant K. pneumoniae was detected in her blood and tracheal aspirate. Her level of consciousness reduced, and clinical condition was deteriorating. The computed tomography scan of the brain revealed abundant pneumocephalus entities. Multidrug-resistant K. pneumoniae was found in her cerebrospinal fluid while on appropriate antibiotic therapy. She died from acute stroke during her treatment.

Techniques for pneumocephalus and brain shift reduction in DBS surgery: a review of the literature

Deep brain stimulation has become an established therapeutic choice to manage the symptoms of medically refractory Parkinson's disease. Its efficacy is highly dependent on the accuracy of electrodes' positioning in the correct anatomical target. During DBS procedure, the opening of the dura mater induces the displacement of neural structures. This effect mainly depends on the loss of the physiological negative intracranial pressure, air inflow, and loss of cerebrospinal fluid. Several studies concentrated on correcting surgical techniques for DBS electrodes' positioning in order to reduce pneumocephalus which may result in therapeutic failure. The authors focused in particular on reducing the brain air window and maintaining the pressure gradient between intra- and extracranial compartments. A significant reduction of pneumocephalus and brain shift was obtained by excluding the opening of the subarachnoid space, by covering the dura mater opening with tissue sealant and by reducing the intracranial pressure in general anesthesia. Smaller burr hole diameters were not statistically relevant for reducing air inflow and displacement of anatomical targets. The review of the literature showed that conserving a physiological intra-extracranial pressure gradient plays a fundamental role in avoiding pneumocephalus and consequent displacement of brain structures, which improves surgical accuracy and DBS long-term results.

High-flow Nasal Cannula-induced Tension Pneumocephalus

High-flow nasal cannula (HFNC) therapy has been established as a promising oxygen treatment with various advantages for respiratory mechanics. One of the main mechanisms is to provide positive airway pressure. This effect could reduce lung injury and improve oxygenation; conversely, it may cause a complication of positive pressure ventilation. However, data are scarce regarding the possible adverse effects, particularly in adults. We report a patient who developed HFNC-induced tension pneumocephalus from an unrecognized skull base fracture. Physicians should be cautious when applying HFNC to patients with suspected skull base or paranasal sinus fracture, especially when applying a higher flow rate.

Pneumocephalus in a Pediatric Patient with Glioma Receiving Trametinib

The mitogen-activated protein kinase (MAPK) pathway consists of the Ras/Raf/MEK/ERK signaling cascade, and its upregulation plays a major role in the pathogenesis of pediatric astrocytomas and molecular inhibitors of this pathway including trametinib and dabrafenib have been tested in early-phase clinical trials and used by pediatric oncologists in children with BRAF-mutated gliomas. We report a clinical case where a child with progressive BRAF-mutated glioma developed an uncommon and difficult to manage complication - pneumocephalus from intracranial air entry and trapping through dehisced surgical wounds and preexisting skull burr holes. The patient's wound breakdown coincided with skin toxicity from MEK inhibitor therapy. With increasing use of targeted molecular inhibitors in pediatric neuro-oncology, this case illustrates the potentially complicated course of MEK inhibitor therapy in patients with scalp surgical wounds and burr holes that were placed within few weeks from initiation of drug therapy, especially if patients have additional factors that can contribute to poor wound healing such as use of steroids and malnutrition.

Frontotemporal dementia: an unusual cause

Intracerebral pneumocephalus is commonly associated with head and facial trauma, ear infection, tumors and surgical interventions. Osteomas are relatively common, benign tumors that occur mainly in the paranasal sinuses, the frontal sinus in particular. Pneumocephalus has been commonly reported with frontal osteoma but isolated presentation as frontotemporal dementia is uncommon. Patient was admitted with complaints of change of behavior and forgetfulness for the last one year. He had progressively become more apathetic and presented with behavioral abnormalities. General physical examinations were within normal limits including the motor and sensory system although neuropsychiatry assessments were below the average level, with features of dementia. Further, MRI brain revealed pneumocephalus in bilateral frontal lobe. CT cisternography revealed a well defined lobulated densely sclerotic lesion of approximate size 20 × 17 × 27mm transverse and cranio-caudal axis respectively arising from right ethmoid sinus. Clinically, the association of pneumocephalus and isolated presentation as frontotemporal dementia has not been described to the best of our knowledge. A single case has been described with ethmoid osteoma. Radiological features were suggestive of osteoid osteoma. The uniqueness of the case is the development of dementia with frontotemporal involvement and resemblance with Frontotemporal Dementia. This is the only case with dementia and pneumocephalus (secondary to osteoid osteoma) to best of our knowledge.

Symptomatic pneumocephalus: A rare complication of discal herniation's surgery

Context: We report the case of a 40-year-old woman with no pathological history, operated from an L4-L5 disc herniation by a left unilateral approach. The dura mater enveloping the left L5 root was accidentally injured at its lateral face causing a breach with CSF leakage. This breach could not be sutured. A few hours after waking, the patient presented an agitation followed by three generalized tonico-clonic seizures. Cerebral imaging revealed pneumocephalus. The patient was hospitalized in an intensive care unit. The symptoms gradually faded and the patient was discharged 3 days after surgery.Findings: Pneumocephalus is defined by the presence of air inside the skull. The symptoms of pneumocephalus are generally non-specific and varied, and this complication should also be kept in mind to prevent potentially severe course. The prevention of postoperative pneumocephalus depends on a well-defined strategy in the case of iatrogenic dural tear.Conclusions: Symptomatic pneumocephalus is a very rare complication in the course of lumbar surgery. Conservative therapy may be appropriate even in severe symptomatic manifestations.

Pneumocephalus and pneumorachis after blunt chest trauma without spinal fractures: a case report

Background

Pneumocephalus and pneumorachis, presence of air inside the skull and spinal canal, are mostly seen after neurosurgical procedures and neuraxial anesthesia. They have also been described after penetrating trauma, but never after blunt trauma without adjacent bone fractures.

Case description

We present the case of an 85-year-old white male patient admitted to our intensive care unit after a high velocity car accident. On site clinical evaluation showed normal consciousness with 15/15 Glasgow Coma Scale after a short initial loss of consciousness. The patient was first sent to a nearby hospital where a whole-body computed tomography scan revealed pneumocephalus and pneumorachis and an important left hemopneumothorax with pneumomediastinum with extensive subcutaneous emphysema. The state of the patient quickly worsened with hemorrhagic shock. The patient was sent to our intensive care unit; upon neurosurgical evaluation, no surgical indication was retained due to the absence of skull and spine fracture.

A computed tomography scan performed on day 6 showed total regression of the pneumocephalus and pneumorachis. A follow-up computed tomography scan performed on day 30 revealed no intracranial bleeding or stroke, but a left pleural hernia between ribs 5 and 6. Due to respiratory complications, our patient could not be weaned from ventilator support for a proper neurological examination.

Our patient’s state finally worsened with septic shock due to ventilator-acquired pneumonia leading to multiple organ failure and our patient died on day 37.

Conclusions

This is the first case report to describe pneumorachis and pneumocephalus following blunt trauma with pneumothorax, but no spinal or skull fractures. The mechanism that is probably involved here is a migration of air with subcutaneous emphysema and a pleural hernia into the spinal canal. However, in cases of pneumorachis or pneumocephalus, skull fractures need to be investigated as these require surgery and appropriate vaccination to prevent meningitis.

Spontaneous "pneumo-apoplexy" as a presentation of pituitary adenoma

Cases of spontaneous CSF leak associated with pituitary tumor apoplexy are uncommon in the literature with pneumocephalus or pneumosella being rare, especially spontaneous occurrence of pneumocephalus being extremely rare. We present a case of pituitary macroadenoma apoplexy resulting in spontaneous CSF leak and a large volume of intra-tumoral gas. A 65-year-old female presented with severe headache, profuse rhinorrhea and acute vision loss and was found to have a large sellar and suprasellar lesion with air and hemorrhage with mild peripheral enhancement. The patient underwent trans-sphenoidal tumor resection and repair of skull base for CSF leak with nasoseptal flap placement. Pathology demonstrated a pituitary adenoma exhibiting immunoreactivity for ACTH. To our best knowledge, our case is the first report of features of pituitary tumor apoplexy with hemorrhage and pneumosella, which could be summarized by the term "pneumo-apoplexy".

Probable Clostridium septicum pneumocephalus in a user of natural remedies with newly diagnosed diabetes mellitus type 1

Clostridium septicum encephalitis is a rare cause of spontaneous, non-traumatic pneumocephalus. Systemic infections with this organism have a fulminant course, likely leading to death within 48 hours, and are commonly associated with hematological or colonic malignancies. The effectiveness of an antibacterial regimen is unknown because of a lack of studies. The best prognosis is observed in patients undergoing early surgical intervention for localized intracranial processes. Here we describe a case of rapidly developing C. septicum sepsis as a result of bacteremia and hematogenous spread, resulting in encephalitis and pneumocephalus in a patient without a diagnosed malignancy. The patient presented to the emergency department with diabetic ketoacidosis, which led to the diagnosis of new-onset type 1 diabetes mellitus. There are currently 19 reported cases of C. septicum central nervous system infections in the literature, with 12 of them having pneumocephalus. Natural remedies, such as drinking kombucha tea and performing coffee enemas, that were used by our patient may have played a role in the dissemination of C. septicum. In survivors of this fulminant illness, colonic and hematologic malignancies should be excluded because of their association with such infections. Type 1 diabetes mellitus, drinking kombucha tea, and performing coffee enemas may be newly recognized risk factors associated with the dissemination of C. septicum.

Symptomatic Pneumocephalus After Spinal Intradural-Extramedullary Tumor Surgery

OBJECTIVE

Durotomy is a necessary procedure for resection of spinal intradural-extramedullary (IDEM) tumor. The purpose of this study was to investigate the prevalence and clinical implications of pneumocephalus after spinal IDEM tumor surgery and also the association between pneumocephalus and postoperative headache.

METHODS

This prospective study was conducted in a cohort of 20 patients who were diagnosed with a spinal IDEM tumor and underwent surgical resection. The mean patient age was 53.6 years (range, 29-75 years). Histological findings revealed schwannoma in 16 cases (80.0%) and meningioma in 4 cases (20.0%). Brain computed tomography scan was performed immediately after surgery. The prevalence and severity were analyzed based on the classification into 4 groups according to the extension of pneumocephalus: absence, mild, moderate, and severe. A visual analog scale (VAS; range 0-10) for headache was reported daily for the first postoperative week. Headache-related pneumocephalus was defined as a VAS score of ≥5 points at least once in that 1-week period.

RESULTS

The prevalence of pneumocephalus was 90.0% (18 patients). Five patients (25.0%) had severe pneumocephalus extending to the extra-axial space. Seven of the 20 patients (38.9%) complained of significant headache. Five of these patients had severe pneumocephalus, 1 patient had moderate pneumocephalus, and 1 patient had moderate pneumocephalus. A statistically significant association was observed between the severity of pneumocephalus and headache (P = 0.001).

CONCLUSIONS

Pneumocephalus is a common complication after spinal IDEM tumor surgery. This report is the first study to investigate the prevalence of pneumocephalus and analyze its association with headache after spine surgery. The severity of pneumocephalus was significantly related to postoperative headache.

Postoperative pneumocephalus increases the recurrence rate of chronic subdural hematoma

OBJECTIVES

Pneumocephalus is a common operative complication of chronic subdural hematoma. This study is to analyze the relationship between postoperative pneumocephalus and the recurrence and surgical outcomes.

PATIENTS AND METHODS

This is a retrospective case-cohort study, including a pneumocephalus group (n = 46) and a control group (n = 181). Their recurrence rates, CT attenuation values, hospital stay, healing time and the neurological status were recorded and analyzed.

RESULTS

The pneumocephalus group had a recurrence rate of 32.6%, significantly higher than the control (17.7%). In addition, the pneumocephalus group had a higher rate of postoperative epilepsy (21.7% vs 3.3%), longer hospital stay (11.5 ± 2.8 vs 7.8 ± 1.2 days), longer healing time (10.8 ± 5.4 vs 6.5 ± 2.3 months), and worse neurological scores than the control.

CONCLUSION

Pneumocephalus increases the recurrence rate of chronic subdural hematoma, and it not only prolongs the hospital stay and healing time, but also leads to deterioration of the neurological status.

Pneumocephalus and orbital emphysema associated with the use of an autoinflation device: a unique case report and review of the literature

BACKGROUND

Autoinflation devices are commonly used for otitis media with effusion and Eustachian tube dysfunction. Generally, these are very safe devices, with few or no complications.Case reportThis paper presents a case study of pneumocephalus and orbital emphysema, associated with the use of an autoinflation device, in a 73-year-old woman with Eustachian tube dysfunction and otitis media with effusion, and a history of extensive endoscopic sinus surgery 13 years previously.

CONCLUSION

A literature review showed autoinflation-related pneumocephalus in patients with skull base defects relating to cranial surgery or tumours; however, this has not been described previously with the Otovent system or its use in relation to functional endoscopic sinus surgery. Given the theoretical risk of undetected bony abnormalities in post-operative functional endoscopic sinus surgery patients, it is suggested that autoinflation devices are used cautiously in patients with a history of sinus surgery.

A prospective randomized clinical trial to evaluate the impact of intraoperative ventilation with high oxygen content on the extent of postoperative pneumocephalus in patients undergoing craniotomies

Purpose of the article: To determine whether intraoperative ventilation with pure oxygen during the last stage of surgery reduces the occurrence and volume of postoperative pneumocephalus when compared to conventional air/oxygen mixture in patients undergoing craniotomy.

MATERIAL AND METHODS

prospective randomized single-blinded study to compare the rate of occurrence and volume of postoperative pneumocephalus in patients undergoing craniotomy receiving intraoperative ventilation with pure oxygen (Group B) versus a conventional air/oxygen 1:1 mixture (Group A) during the last stage of surgery. This trial was registered in ClinicalTrials.gov #NCT02722928, protocol number 2015H0032.

RESULTS

One hundred patients were randomized into group 'A' and group 'B'. Seventy patients were included in the final analysis with 39 patients allocated in group 'A' and 31 patients in group 'B'. Median and IQR were used for postoperative penumocephalus volume. Group A: 9.65 [3.61-23.20]; Group B: 7.06 [2.70-20.1]. Our study showed no prophylactic effect on postoperative pneumocephalus volume when using mechanical ventilation with higher oxygen concentrations than the standard FiO₂ during the last stage of surgery in patients undergoing craniotomy (p = .47). No statistical difference was found in SICU LOS between groups (median 1,380 min [group A] versus 1,524 min [group B]; p = .18).

CONCLUSION

The use of intraoperative mechanical ventilation with pure oxygen was not associated with a prophylactic effect on the occurrence and extent of postoperative pneumocephalus in our patient setting. Published literature describing the extent of postoperative pneumocephalus is limited or highly variable among institutions.