Traumatic tension pneumocephalus: Two case reports

Traumatic tension pneumocephalus: a case report and perspective from Indonesia

Traumatic tension pneumocephalus is a rare and life-threatening complication of traumatic brain injury necessitating prompt diagnosis and neurosurgical treatment. Nevertheless, various possibilities for impedance in timely management, including patient-related barriers are commonly experienced in low-and middle-income countries setting. Here we presented a delay of management in traumatic tension pneumocephalus case due to initial refusal for emergency surgery. A 59-year-old male presented to the emergency department following a motorcycle accident fully alert with no neurological deficit. He acknowledged clear nasal discharge within 1 h after the initial trauma, but no rhinorrhea or otorrhea was present during physical examination. Head CT revealed extensive pneumocephalus with "Mount Fuji sign," anterior skull base fracture, and frontal sinus fracture. The patient initially refused immediate surgical intervention due to excellent clinical condition and financial scare. Acute decrease of consciousness occurred 40 h post-trauma: GCS of 6 with slight dilatation of both pupils (4 mm) and sluggish pupillary reflex. Emergency bifrontal craniotomy, subdural air drainage, and dura mater tear repair were performed afterwards. Postoperative care was uneventful, with rapid improvement of consciousness and follow-up head CT showing minimal subdural fluid collection and absence of remaining pneumocephalus. The patient was discharged from the hospital after 7 days with GCS of 15 and GOS of 5, proving the importance of overcoming barriers for delay in delivering neurotrauma care in low-and middle-income countries.

Tension pneumocephalus following cranioplasty with a titanium plate: a case report

Tension pneumocephalus (TP) can be a life-threatening postoperative complication, but there are limited data owing to its exceedingly low frequency. A 48-year-old man that suffered a head injury survived the acute phase and cranioplasty was performed using a titanium plate. Progressive deterioration of consciousness occurred the day after the cranioplasty. Computed tomography showed the presence of expanded air in the left epidural cavity and a midline shift to the right side. Emergency skin flap reopening was performed. Tension of the scalp decreased when the skin suture was cut and the wound reopened. Lucidity and improved right hemiparesis were obtained within a few hours after drain insertion. Pooled air in the left epidural cavity gradually dissipated postoperatively and the epidural drain was removed 2 days after insertion. The patient was discharged 27 days after cranioplasty, with a modified Rankin scale score of 2. The mechanism that caused TP was considered. Specifically, the skin flap acted as a one-way valve and trapped air. Then the trapped air expanded as the patient’s body temperature warmed. TP should be considered a differential diagnosis after craniotomy. Emergency skin flap reopening and drain insertion may be an effective treatment for TP in the epidural space.

Delayed Tension Pneumocephalus Following Frontal Sinus Fracture

Case Presentation

We describe a delayed case of tension pneumocephalus in a newly altered patient 21 days status-post auto-vs-pedestrian accident. After her initial hospital course, the patient was discharged to an acute rehabilitation facility in stable condition with Glasgow Coma Scale 15. The patient returned to the emergency department for an acute change in mental status.

Discussion

Tension pneumocephalus is a neurosurgical and otolaryngological emergency.

The Role of Endonasal Endoscopic Skull Base Repair in Posttraumatic Tension Pneumocephalus

OBJECTIVES

Information about the endonasal endoscopic approach (EEA) for the management of posttraumatic tension pneumocephalus (PTTP) remains scarce. Concomitant rhinoliquorrhea and posttraumatic hydrocephalus (PTH) can complicate the clinical course.

METHODS

The authors systematically reviewed pertinent articles published between 1961 and December 2020 and identified 6 patients with PTTP treated by EEA in 5 reports. Additionally, the authors share their institutional experience including a seventh patient, where an EEA resolved a recurrent PTTP without rhinoliquorrhea.

RESULTS

Seven PTTP cases in which EEA was used as part of the treatment regime were included in this review. All cases presented with a defect in the anterior skull base, and 3 of them had concomitant rhinoliquorrhea. A transcranial approach was performed in 6/7 cases before EEA was considered to treat PTTP. In 4/7 cases, the PTTP resolved after the first intent; in 2/7 cases a second repair was necessary because of recurrent PTTP, 1 with and 1 without rhinoliquorrhea, and 1/7 case because of recurrent rhinoliquorrhea only. Overall, PTTP treated by EEA resolved with a mean radiological resolution time of 69 days (range 23-150 days), with no late recurrences. Only 1 patient developed a cerebrospinal fluid diversion infection probably related to a first incomplete EEA skull base defects repair. A permanent cerebrospinal fluid diversion was necessary in 3/7 cases.

CONCLUSIONS

Endonasal endoscopic approach repair of air conduits is a safe and efficacious second-line approach after failed transcranial approaches for symptomatic PTTP. However, the strength of recommendation for EEA remains low until further evidence is presented.

Expanding pneumocephalus due to craniofacial fractures: A case report

Introduction

Pneumocephalus (PNC) is the presence of air in the intracranial cavity. The most frequent cause is craniofacial trauma, though there are many etiologies, including surgical procedures. PNC with compression of the frontal lobes and widening of the interhemispheric space between the tips of the frontal lobes results in the characteristic radiological finding of the “Mount Fuji sign”.

Presentation of case

A 57-year-old man presented to the A&E with loss of consciousness due to a motorcycle collision 9 h prior. He had a GCS of E4M6V5, and a head CT scan revealed minimal PNC forming in both hemispheres. After discharge, severe headaches and rhinorrhea developed. A second CT scan revealed a massive PNC. An operation was then performed via a bicoronal incision to drain the PNC and seal the cranial defect. A burr hole in the calvarium was created, and the cranial defect was closed using a pericranial rotational flap. Post-operation, the patient's headache and rhinorrhea decreased; neither symptom was present at 1-month post-operation. The wounds healed with minimal scarring, and the cosmetic outcome for the craniofacial fracture was acceptable.

Discussion

Although the patient may at first present with a mild head injury, this can progress into something much more serious. PNC is difficult to diagnose clinically. Rarely, patients describe a splashing sound upon moving the head (termed bruit hydro-aerique), which can also be auscultated. A head CT scan is the gold standard in the diagnosis of PNC. Pericranial flaps are widely used for dural repair because they are easily accessible and have a lower rate of infection than artificial grafts on expanding PNC.

Conclusion

Tension PNC may be slow-growing and increase intracranial pressure to high levels before clinical signs are present. The pericranial rotational flap technique is the best way to close a dura mater defect in cranial base fractures with tension PNC.

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Pneumocephalus (PNC) is the presence of air in the intracranial cavity.

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Craniofacial trauma is the most frequent cause of PNC.

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We report a male with expanding PNC who required a pericranial rotational flap.

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Tension PNC may be slow-growing and increase intracranial pressure to high levels before clinical signs are present.

Tension pneumocephalus and bilateral orbital compartment syndrome relieved by lateral canthotomies

Traumatic tension pneumocephalus and orbital compartment syndrome are rare, tend to be associated with severe craniofacial injuries, and can occur following both blunt and penetrating injury. Early recognition and high index of clinical suspicion are important in both cases. Emergency decompression results in improvement in vast majority of cases.

Tension Pneumocephalus in a Tracheostomized, Chronically Ventilated, Duchenne's Muscular Dystrophy Patient Without Prior Head Trauma

Tension pneumocephalus is a rare condition that can be a life-threatening neurosurgical emergency. It usually results from head trauma, but there have been case reports of iatrogenic causes including on non-invasive mechanical ventilation. We report a case of pneumocephalus resulting from high mechanical ventilation pressures in a patient without prior head trauma. A 37-year-old male with Duchenne's muscular dystrophy who had been ventilator-dependent through tracheostomy was admitted for shortness of breath and intermittent fevers. The patient was found to have pneumonia, with left-lower lobe consolidation, and was started on linezolid given known Methicillin-resistant Staphylococcus aureus from previous sputum culture; he was later switched to vancomycin and piperacillin-tazobactam given persistent fevers to cover for hospital-acquired pneumonia. The patient went into septic shock requiring multiple pressors as well as stress steroids for persistent shock, with eventual improvement in hemodynamics. He developed further respiratory acidosis on his usual ventilator settings, and peak inspiratory pressures (PIPs) progressively increased to as high as 45-70 cm H₂O during his hospital course. PIPs did not improve with suctioning or after bronchoscopy. On the 17th day of the patient's stay, he had acutely altered mental status with non-reactive fixed and dilated pupils and disconjugate gaze of the right eye on neurologic examination. CT of the head at that time revealed extensive pneumocephalus along the bifrontal convexities, suprasellar cisterns, and posterior fossa, with a possible fracture of the frontal skull base near the ethmoid roof. Mount Fuji sign was present on CT scan, indicative of "tension pneumocephalus". Neurosurgical consultation was obtained but the family declined intervention given his overall debilitated stated. Comfort measures were instituted, and the patient expired the following day. Pneumocephalus is the accumulation of air entry into the cranial cavity, generally from head trauma, inflammation, or surgery. Patients may have underlying base skull defects or microfractures that permit air to enter the intracranial cavity. Increased sphenoid sinus pressure from mechanical ventilation may enter the subperiosteal space, allowing air to enter the intracranial cavity. It is important to consider pneumocephalus in a patient with new neurological findings after mechanical ventilation.

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.

Delayed tension pneumocephalus following decompressive craniectomy

Pneumocephalus is defined as a collection of air in the cranial cavity and is a common finding following intracranial neurosurgical procedures or following skull base fractures. The term tension pneumocephalus describes the accumulation of air under pressure such that it exerts mass effect and leads to a neurological deterioration. Whilst this is a rare event it can be life threatening and requires prompt intervention. We describe a case that occurred in a delayed fashion following a decompressive craniectomy for a severe traumatic brain injury. It was initially treated by urgent aspiration at a peripheral hospital under neurosurgical guidance.

Proper Management of Posttraumatic Tension Pneumocephalus

Pneumocephalus is commonly seen after craniofacial injury. The pathogenesis of pneumocephalus has been debated as to whether it was caused by ball valve effect or combined episodic increased pressure within the nasopharynx on coughing. Discontinuous exchange of air and cerebrospinal fluid due to “inverted bottle” effect is assumed to be the cause of it. Delayed tension pneumocephalus is not common, but it requires an active management in order to prevent serious complication. We represent a clinical case of a 57-year-old male patient who fell down from 3 m height, complicated by tension pneumocephalus on 5 months after trauma. We recommend a surgical intervention, but the patient did not want that so we observe the patient. The patient was underwent seizure and meningitis after 7 months after trauma, he came on emergency room on stupor mentality. Tension pneumocephalus may result in a neurologic disturbance due to continued air entrainment and it significantly the likelihood of intracranial infection caused by continued open channel. Tension pneumocephalus threat a life, so need a neurosurgical emergency surgical intervention.