Treatment of Postcraniotomy Tension Pneumocephalus via Endoscopic Closure of the Nasofrontal Recess

[Management of complex skull base defects accompanied by pneumocephalus]

AIM

The study aim was to analyze our own experience in treating patients with complex skull base defects accompanied by pneumocephalus and, based on the findings, to develop an optimal treatment approach for this pathology.

MATERIAL AND METHODS

We retrospectively reviewed a series of 30 patients with complex skull base defects accompanied by pneumocephalus who underwent inpatient treatment at the Burdenko Neurosurgical Institute in the period from 2001 to 2017. We analyzed demographic characteristics of patients (gender, age), clinical data (etiology, somatic and neuropsychiatric status, radiological data), and treatment aspects (conservative or surgical treatment, used approach, defect characteristics, reconstructive materials). Treatment outcomes were assessed based on analysis of changes in clinical manifestations, postoperative complications, and recurrences. The obtained data were compared to the results of literature review.

RESULTS

In the series of 30 patients with complex skull base defects accompanied by pneumocephalus, the mean age was 41 years (range, 17-68 years); there were 17 (59%) males and 13 (41%) females. Etiologically, there were 17 (59%) traumatic cases, 11 (36%) iatrogenic cases, and 2 (5%) spontaneous cases. Clinically, the patients presented with the following manifestations: psycho-neurological symptoms (41%), nasal cerebrospinal fluid (CSF) leak (36%), impaired consciousness (27%), and meningitis (23%). Eight patients with acute injuries underwent complex conservative treatment that included infusion, and anti-edema, vascular, metabolic, anticonvulsant, and antibacterial therapy. In cases of conservative treatment failure or tension pneumocephalus accompanied by abrupt worsening of the patient's condition, surgical treatment was used. A total of 24 interventions (including revision surgery) were performed in 22 patients. All patients underwent endoscopic endonasal reconstruction of complex skull base defects. Tissues used for reconstruction included the fascia lata and adipose tissue (77%), fascia lata and cartilage/bone from the nasal septum (14%), and a pedicled nasoseptal flap (9%). The success rate of reconstructive interventions was 91%. There were 2 (9%) recurrences. Postoperative complications in the form of meningitis occurred in 4 (18%) patients.

CONCLUSION

In the case of a nasal cerebrospinal leak history and worsening of the patient's condition accompanied by common cerebral and psychiatric symptoms, the development of pneumocephalus should be considered first, the early diagnosis of which will facilitate choosing the correct treatment approach. In the case of acute injury in patients with the established diagnosis of pneumocephalus caused by gas-forming infection, conservative therapy is indicated in the early period after neurosurgical interventions with opening of the meninges. Tension pneumocephalus together with a skull base bone defect (according to CT) and a nasal CSF leak history is the indication for surgical treatment. In this case, the endoscopic endonasal technique is the method of choice.

Endoscopic management of skull base defects associated with persistent pneumocephalus following previous open repair: A preliminary report

Objective: To describe the management of anterior skull base defects in patients who present with pneumocephalus after previous open neurosurgical intervention.

Study Design: Case series with chart review.

Setting: Tertiary referral center.

Subjects and Methods: Patients repaired endoscopically for symptomatic pneumocephalus between April 1, 2005, and July 1, 2008. Volumetric calculation of the amount of intracranial air based on the preoperative CT scan was performed.

Results: Six patients met inclusion criteria. The etiology of skull base defects was accidental trauma in two patients and surgical trauma in the remaining four. Average time from the open intervention until endoscopic repair was 28 days. Intrathecal fluorescein was utilized in five cases, but visualized at the site of the defect in only one patient. All patients were treated with a similar endoscopic technique. A simple free mucosal graft was used in four patients; a mucosal graft was placed over a layered reconstruction consisting of acellular dermal matrix in two patients, with one patient receiving septal cartilage. Closure of defects was achieved in all six patients with complete resolution of pneumocephalus in five patients after an average of 17 days; one patient had trace amounts of pneumocephalus (< 2 cc) at 10 days. Mean follow-up was seven months.

Conclusion: Endoscopic techniques employed in this preliminary report demonstrate promising results in managing skull base defects associated with clinically significant pneumocephalus following failed prior open neurosurgical repair. The small population size in this study, however, precludes definitive conclusions regarding efficacy.