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

Pneumocephalus and empyema in the subarachnoid space: An unusual imaging feature secondary to spinal-epidural anesthesia

Pneumocephalus and empyema in the subarachnoid space secondary to spinal-epidural anesthesia are very rare and have not previously been reported, to our knowledge. Here, we describe the imaging features of an older woman presenting with pneumocephalus plus subarachnoid and intraventricular empyema due to Staphylococcus epidermidis infection after spinal-epidural anesthesia, with the aim of raising awareness regarding this serious complication.

Narrative review of traumatic pneumorrhachis

Pneumorrhachis (PR) is defined as presence of free air in the spinal canal. Traumatic PR is very rare, and its exact incidence and pathogenesis is unknown. A comprehensive literature search was performed using the PubMed, Cochrane Library, Google Scholar and Scopus databases to identify articles relevant to traumatic PR published till January 2023. A total of 34 resources were selected for inclusion in this narrative review. Traumatic PR can be classified anatomically into epidural and intradural types. In the epidural type, air is present peripherally in the spinal canal and the patients are usually asymptomatic. In contrast, in intradural PR, air is seen centrally in the spinal canal and patients present with neurological symptoms, and it is a marker of severe trauma. It is frequently associated with traumatic pneumocephalus, skull fractures or thoracic spine fracture. Computed tomography (CT) is considered to be the diagnostic modality of choice. Epidural PR is self-limited and patients are generally managed conservatively. Patients with neurological symptoms or persistent air in spinal canal require further evaluation for a potential source of air leak, with a need for surgical intervention. Differentiation between epidural and intradural PR is important, because the latter is an indication of severe underlying injury. CT imaging of the entire spine must be performed to look for extension of air, as well as to identify concomitant skull, torso or spinal injuries Most patients are asymptomatic and are managed conservatively, but a few may develop neurological symptoms that need further evaluation and management.

Traumatic pneumocephalus as a possible early sign of acute spinal cord injury: Case report

Background

Traumatic pneumocephalus (TPC) following craniofacial injuries is common, but isolated TPC secondary to pneumorrhachis (PR) is the rare result of upward gas migration from the spinal canal. In the absence of craniofacial and grossly unstable spinal fractures, the etiology of TPC in polytrauma can be elusive and an underlying diagnosis of acute spinal cord injury (SCI) can be easily missed. We report the first polytrauma case where TPC was the most reliable early sign of SCI.

Case Description

A 34-year-old polytrauma female with imaging findings of TPC, which was later found to be secondary to an underlying SCI. As a focused exam could not be performed at admission, the TPC was first attributed to undiagnosed craniofacial injuries. Tertiary survey revealed the patient being paraplegic and MRI workup demonstrated an acute SCI at the T3-T4 level. PR was the most likely cause of TPC in the absence of other craniofacial injuries.

Outcome

The patient did not have a meaningful recovery given the extensive hemispheric infarcts, spinal cord injury, and respiratory failure.

Conclusions

Although uncommon, TPC may be an important radiographic sign suggesting the possibility of an underlying SCI in polytrauma patients. especially when focused neurologic assessment is limited at admission. Polytrauma patients with TPC and PR in the absence of coexisting craniofacial fractures require an urgent spine consultation by the ER physician, with possible early spine MRI workup. We suggest a diagnostic algorithm for the early identification of SCI in polytrauma patients presenting with TPC and propose considering 3 groups which may have different risks for SCI based on their clinical presentation and the presence of PR.

Case 301: Traumatic Subarachnoid-Pleural Fistula

HISTORY

A 38-year-old man who had been in a motor vehicle collision was referred to our institute. He was suspected of having left-sided pneumothorax. This necessitated intercostal drainage with a chest tube, which had been placed elsewhere prior to his arrival. Paraparesis was noted at the initial clinical examination, with adequately maintained vital signs, while the blood work-up revealed a mildly reduced hemoglobin level of 10.1 mg/dL (normal range, 13.8-17.2 mg/dL); however, the rest of the laboratory values were within normal limits. The patient was then immediately referred for further evaluation with CT of the brain, cervical spine, and thorax. Thereafter, serial chest radiography was performed for follow-up.

Pneumorachis and pneumocephalus: Case report of a rare blunt chest trauma complication

Introduction

Pneumorachis, air in the spinal canal, is very rare and its association with pneumocephalus following blunt thoracic trauma remains exceptionally uncommon.

Case presentation

We present the case of a 65-year-old patient, a pedestrian hit by a car driving at very high speed. The lesion assessment on admission showed a bilateral hemothorax of moderate abundance, a right pneumothorax of low abundance and a left pneumothorax of moderate abundance, subcutaneous cervico-dorsal emphysema, pneumocephalus and significant pneumorachis at the cervico-dorsal level without fracture of the base of the skull, sinuses or the spine.

Discussion

We discuss the different etiologies of pneumorachis, the main hypotheses of the constitution of this air effusion and the principles of management.

Conclusion

Pneumorachis associated with pneumocephalus in a traumatic context without bone lesions is an extremely rare entity, its discovery should lead to further investigations to look for any spinal or basilar skull fracturethat could expose to an infectious risk or require a surgical procedure.

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The pneumorrachis was first described in 1977.

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Pneumorachis is mainly reported as an iatrogenic complication, and more rarely traumatic.

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Pneumorachis associated with pneumocephalus in a traumatic context without bone lesions is an extremely rare entity.

Persistent Air Embolism after Blunt Chest Trauma with Recovery to Pre-Existing Consciousness Level: A Case Report and Literature Review

We report the case of a 71-year-old woman in whom cerebral air embolism resulted from blunt chest trauma. The woman had been lying on her left side for a while after the injury, and air traveled to the right side of the brain. As a result, a cerebral infarction occurred in the right cerebral hemisphere that caused loss of consciousness for more than 40 days. The patient recovered consciousness eventually; thus, it is important to monitor the improvement in a patient's state of consciousness, with repeated multi-modality imaging evaluations over a long period.

Tension Pneumocephalus From an Eroding Cholesteatoma: A Case Report and Review of the Literature

Pneumocephalus is defined as the presence of air inside the cranial vault. Benign and tension pneumocephalus are different ends of the same disease spectrum. Tension pneumocephalus leads to the formation of a pressure gradient, requiring emergent surgical decompression to prevent herniation of the intracranial structures. In this report, we present a rare case of tension pneumocephalus with essentially benign radiological findings secondary to a ruptured cholesteatoma. The patient was a 64-year-old woman with a history of end-stage renal disease on hemodialysis and hypertension. She presented to the emergency department (ED) with acute-onset weakness and decreased mentation. Physical exam findings were consistent with a cerebrovascular accident (CVA). CT scan and CT angiogram (CTA) were unremarkable for ischemia or hemorrhage but showed signs of free intracranial air, consistent with the diagnosis of pneumocephalus. After the activation of the code stroke, neurosurgery and neurology were consulted. Worsening respiratory status led to a decision to proceed with emergent intubation, but it was held based on the family’s decision to proceed with comfort measures. The patient’s status declined further within minutes and she died. Afterward, the case was discussed with the radiologist, who interpreted the cause as a cholesteatoma that had eroded through the temporal bone.

A Case of Atraumatic, Streptococcal Pneumocephalus: A Rare Complication of Influenza B Infection

Patient: Female, 51-year-old

Final Diagnosis: Pneumocephalus • Pneumococcal meningitis

Symptoms: Worsening of mental status

Medication:—

Clinical Procedure: —

Specialty: Critical Care Medicine • Infectious Diseases • General and Internal Medicine

A Case of Traumatic Pneumocephalus on the Opposite Side of the Injury Site

Pneumocephalus is defined as an abnormal presence of intracranial air or gas. Traumatic pneumocephalus (TP) typically occurs on the injured side and is in communication with the external environment. This report presented an extremely rare case of TP that occurred on the opposite side of the injured site, even with the absence of any traumatic injury. The patient sustained injuries, including linear skull fracture, acute epidural hematoma, fractures in the clavicle and scapula, and subcutaneous emphysema, on the left side of the body. However, TP occurred on the right side. Although the exact underlying pathogenic mechanism remains unclear, the condition might be attributed to the migration of air bubbles or negative pressure on the opposite side caused by side-to-side closed head injury.