Spontaneous Tension Pneumocephalus: A Rare Complication of Shunting

Hidden intra-meatal CSF fistula related to VP shunt as a cause for fatal tension pneumocephalus after vestibular schwannoma resection

BACKGROUND

Cerebrospinal fluid (CSF) leak through petrosal air cells is a known complication after drilling the posterior wall of the internal acoustic canal (IAC) for resection of vestibular schwannoma (VS). Whereas mild pneumocephalus is common after retrosigmoid craniotomy, tension pneumocephalus has been rarely documented.

OBJECTIVE

To testify a case of fatal tension pneumocephalus after VS resection in a patient with ventriculo-peritoneal (VP) shunt and to propose possible recommendations to limit the risk of this dramatic complication.

METHODS

A case of fatal tension pneumocephalus after VS resection in presence of hidden CSF fistula is illustrated with pre- and post-operative images.

RESULTS

In the uneventful situation of concomitant post-operative CSF fistula in presence of VP shunt, tension pneumocephalus may occur. The negative pressure created by the shunt system and the presence of osteo-dural defect allow the air to enter and, at the same time, prevent the outflow.

CONCLUSION

After VS resection, tension pneumocephalus can occur as a consequence of CSF fistula from petrosal air cells in the presence of functioning VP shunt. Precautions as pre-operative increase to 'virtual-off' the pressure of the valve, subsequences CT scans after surgery and sealing of the petrous air cells are recommended to avoid such as fatal complication.

Tension pneumocephalus in a patient with NF1 following ventriculoperitoneal shunt-deciphering the cause and proposed management strategy

INTRODUCTION

Spontaneous pneumocephalus following ventriculoperitoneal shunting is a very unique complication, seen in a handful of patients. Small bony defects form as a result of chronically raised intracranial pressure, which can later lead to pneumocephalus once intracranial pressure decreases following ventriculoperitoneal shunting.

CASE REPORT

Here, we present a case of a 15-year-old girl with NF1 who presented to us with pneumocephalus 10 months following shunting and our management strategy along with a literature review of this condition.

CONCLUSION

NF1 & hydrocephalus can lead to skull base erosion, which needs to be looked up before proceeding with VP shunting to avoid delayed onset pneumocephalus. SOKHA with the opening of LT is a minimally invasive approach suitable to tackle both problems simultaneously.

Tension Pneumocephalus Following LP Shunt due to Congenital Bone Defects: A Case Report

A 72-year-old man who had undergone a lumboperitoneal shunt for idiopathic normal pressure hydrocephalus was admitted to our emergency department with fever and disturbance of consciousness 8 days after placement. Computed tomography scan showed pneumocephalus and a right-sided temporal porencephalic cyst with a small bone defect in the right petrous bone. Shunt valve pressure was raised from 145 mmH₂O to "virtual off" setting. After 2 weeks, follow-up computed tomography showed improvement of pneumocephalus, and the shunt valve pressure was lowered to 215 mmH₂O. Since that time, the patient has a good clinical course without recurrence. Tension pneumocephalus following shunt placement for idiopathic normal pressure hydrocephalus is rare and has never been reported in the early postoperative stage after lumboperitoneal shunt, except for the present one. Temporary raising shunt valve pressure is effective in improving the pneumocephalus. Preoperative screening for congenital bone defects by thin-slice computed tomography may be useful for selecting types of shunt valve and determining postoperative pressure setting.

Tension pneumoventricle in a patient with a ventriculoperitoneal shunt and an ethmoidal meningoencephalocele

Background:

Tension pneumoventricle is a rare, life-threatening complication. It has been rarely described in patients with ventriculoperitoneal (VP) shunts.

Case Description:

A 28-year-old male patient with a VP shunt became progressively lethargic after falling from his wheelchair. Skull X-rays and head CT scan showed abundant air inside the ventricles. He was taken to the operating room, and the shunt was revised without improvement. Two days later, a frontal external ventricular drain was placed to remove the air. In the investigation toward the etiology of the pneumoventricle, a review of previous head CT scans and brain MRIs showed that the patient had a small left frontonasal meningoencephalocele extending into the ethmoid, which had been unnoticed. He underwent repair of the defect with adequate sealing of the frontal skull base.

Conclusion:

In a shunted patient with moderate or severe symptoms from a tension pneumoventricle, external ventricular drainage is required to remove the air as the shunt is inadequate.

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.

A Rare Case of Temporal Bone Pneumocephalus Tracking through the Internal Auditory Canal

A 39-year-old male with chronic hydrocephalus requiring biventricular shunts presented with progressive pneumocephalus over several years. He showed no improvement following ventriculoperitoneal (VP) shunt revision and anterior skull base repair for a sphenoid dehiscence. Imaging continued to show worsening pneumocephalus with air tracking along the right facial nerve from the geniculate ganglion to the internal auditory canal (IAC). The patient then underwent tympanomastoidectomy and skull base reconstruction. Based on a search of published literature, this appears to be the first reported case of temporal bone pneumocephalus coursing through the IAC, unlike most cases associated with tegmen defects and middle fossa pneumocephalus.

Acute Deafness: A Rare Complication of Shunting

BACKGROUND

Mild hearing loss following shunting has been described; however, severe auditory impairment associated with ventriculoperitoneal (VP) shunt is an uncommon, rarely reported phenomenon. Treatment options and pathophysiologic considerations are discussed in this case report.

CASE DESCRIPTION

A 27-year-old man who was treated for an eighth cranial nerve schwannoma with complete resection and a VP shunt 10 years previously presented to the emergency department with acute severe hearing loss and headache. Imaging showed diminished size of the ventricles and dural contrast enhancement. The previous shunt was replaced with a programmable antisiphoning VP shunt. The patient's hearing and headache improved 48 hours later, as demonstrated in serial audiograms.

CONCLUSIONS

Hearing loss is an underestimated complication of shunting that in some cases may progress to severe impairment and deafness. Patients with a VP shunt who experience hearing loss should undergo further evaluation and possibly adjustment of shunt settings.