Review of the management of pneumocephalus

Profound Pneumocephalus and Low-Pressure Hydrocephalus Triggered by Ventriculoperitoneal Shunt Placement after Resection, Fat Graft Reconstruction, and Radiotherapy for a Malignant Skull Base Schwannoma

Background  Tension pneumocephalus is a rare postoperative complication, typically presenting with mental status changes or rapid neurological decline after craniotomy. We report a complex case of tension pneumocephalus triggered by graft retraction after ventriculoperitoneal (VP) shunt placement. Case History  A 39-year-old woman with a recurrent left trigeminal cavernous sinus schwannoma, status post one prior resection, two stereotactic radiosurgery treatments, and one course of fractionated radiotherapy, underwent radical resection with orbital exenteration and abdominal fat free graft reconstruction followed by adjuvant radiotherapy for malignant transformation. She developed subacute ventriculomegaly with altered mental status, prompting VP shunt placement. Three weeks later, she presented with profound pneumocephalus and intraventricular air originating from a large, left-sided sphenoid and maxillary defect, from which the fat graft had retracted. A right frontal external ventricular drain (EVD) was placed, resulting in immediate release of air under high pressure. Definitive treatment required skull base reconstruction with a latissimus dorsi free flap, contralateral nasoseptal flap, antibiotics, and VP shunt revision for treatment of combined cerebrospinal fluid (CSF) leak, pneumocephalus, ventriculitis, and low-pressure hydrocephalus. As of her last follow-up, she was restored to her initial postresection neurological baseline. Conclusion  Tension pneumocephalus is a rare and life-threatening emergency that requires immediate neurosurgical intervention. We report the index case of tension pneumocephalus induced by graft retraction following radiotherapy and CSF diversion. Where observed, tension pneumocephalus resulting from a skull base CSF leak may be associated with low-pressure hydrocephalus, and successful long-term management demands balancing the need for CSF diversion against the integrity of the skull base reconstruction.

Extensive Pneumocephalus Secondary to Petrous Bone Cholesteatoma

Pneumocephalus refers to air inside the cranium; however, otogenic pneumocephalus is rarely reported in the literature. The neurological presentations of pneumocephalus include headache, lethargy, confusion, disorientation, and seizure. Here, we have reported a case of a 42-year-old woman with extensive pneumocephalus and cerebrospinal fluid leak secondary to petrous bone cholesteatoma. She presented to the emergency department with sudden headache and left ear discharge. Physical examination revealed watery otorrhea through a hole in the tympanic membrane. Radiological studies demonstrated extensive soft tissue in the left middle ear and mastoid extending to the internal auditory canal. Free intracranial air was observed, and bony destruction was seen in the cochlea, vestibule, and semicircular canals. The patient was managed surgically via the transotic approach and fully recovered. Although otogenic pneumocephalus is rarely encountered in clinical practice, early diagnosis and urgent management are important to prevent fatal complications.

Minimizing pneumocephalus during deep brain stimulation surgery

BACKGROUND

Deep brain stimulation (DBS) surgery is an effective treatment for movement disorders. Introduction of intracranial air following dura opening in DBS surgery can result in targeting inaccuracy and suboptimal outcomes. We develop and evaluate a simple method to minimize pneumocephalus during DBS surgery.

METHODS

A retrospective analysis of prospectively collected data was performed on patients undergoing DBS surgery at our institution from 2014 to 2022. A total of 172 leads placed in 89 patients undergoing awake or asleep DBS surgery were analyzed. Pneumocephalus volume was compared between leads placed with PMT and leads placed with standard dural opening. (112 PMT vs. 60 OPEN). Immediate post-operative high-resolution CT scans were obtained for all leads placed, from which pneumocephalus volume was determined through a semi-automated protocol with ITK-SNAP software. Awake surgery was conducted with the head positioned at 15-30°, asleep surgery was conducted at 0°.

RESULTS

PMT reduced pneumocephalus from 11.2 cm3±9.2 to 0.8 cm3±1.8 (P<0.0001) in the first hemisphere and from 7.6 cm3 ± 8.4 to 0.43 cm3 ± 0.9 (P<0.0001) in the second hemisphere. No differences in adverse events were noted between PMT and control cases. Lower rates of post-operative headache were observed in PMT group.

CONCLUSION

We present and validate a simple yet efficacious technique to reduce pneumocephalus during DBS surgery.

Spinal procedures, pneumocephalus, and cranial nerve palsies: A review of the literature

Purpose: Minimally invasive and surgical spine procedures are commonplace with various risks and complications. Cranial nerve palsies, however, are infrequently encountered, particularly after procedures such as lumbar punctures, epidural anesthesia, or intrathecal injections, and are understandably worrisome for clinicians and patients as they may be interpreted as secondary to a sinister etiology. However, a less commonly considered source is a pneumocephalus which may, in rare cases, abut cranial nerves and cause a palsy as a benign and often self-resolving complication. Here, we present the case of a patient who underwent an intrathecal methotrexate infusion for newly diagnosed non-Hodgkin's T-cell lymphoma and subsequently developed an abducens nerve palsy due to pneumocephalus. We highlight the utility of various imaging modalities, treatment options, and review current literature on spinal procedures resulting in cranial nerve palsies attributable to pneumocephalus presenting as malignant etiologies.

Sudden-onset, non-traumatic large volume pneumocephalus following presentation of acute bacterial meningitis

A man in his 30s, with sinonasal undifferentiated carcinoma status post resection 6 years prior, presented with acute onset of fever, headache and altered mentation. The patient was diagnosed with bacteremia and meningitis due to Streptococcus pneumoniae A standard antibiotic and corticosteroid regimen was started. Brain MRI showed an encephalocele abutting the superolateral nasopharynx mucosa. After several days of clinical improvement, the patient's mental status and headache acutely relapsed. A CT head venogram showed a large volume pneumocephalus originating from the region of a surgical defect. Management included external ventricular drain placement followed by right pterional craniotomy with skull base packing. Skull base defects increase the risk of life-threatening conditions such as bacterial meningitis and pneumocephalus. It is crucial for clinicians to be aware of the possibility of cranial surgical defects developing years after surgery.

Use of oxygen therapy for pneumocephalus: a systematic review

Pneumocephalus is the pathologic collection of air in the intracranial cavity. In sufficient volumes, it can contribute to symptoms ranging from headaches to death. For conservative treatment, oxygen use is commonplace. Although this is an accepted tenet of clinical practice, it is not necessarily founded on robust trials. An electronic search of databases EMBASE and MEDLINE and the Cochrane Library was undertaken as per the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. Three articles were included. Although the modes of oxygen delivery were heterogenous (non-rebreather versus endotracheal versus hyperbaric chamber), all studies concluded favorably on the use of oxygen therapy for increased reabsorption of pneumocephalus.

Early Mobilization and Rehabilitation to Enhance the Functional Performance of a Hemiparesis Patient Following a Subdural and Subarachnoid Hematoma With Pneumocephalus: A Case Report

A subdural hematoma (SDH) is a medical condition caused by a violent head trauma in which blood accumulates excessively under the dura mater. It occurs when a blood arterial weak point or brain surface aneurysm ruptures and bleeds. The resulting blood accumulation inside and around the skull raises the pressure on the brain. Pneumocephalus, also known as pneumatocele or intracranial aerogel, refers to air in the ventricular cavities or brain parenchyma's epidural, subdural, or subarachnoid spaces. In most cases, neurotrauma is the primary cause of pneumocephalus, mainly when there are skull base fractures. Here, we present a case study of a 65-year-old male patient diagnosed with left hemiplegia following SDH with subarachnoid hematoma (SAH) and pneumocephalus. The severity of the patient's illness, the medical and surgical care provided, the amount of physiotherapy required to aid recovery, the duration of hospitalization, and the discharge location for patients with acute SAH or SDH vary significantly. The patient underwent physiotherapy rehabilitation, and we report that his lower limb strength improved substantially after the therapy. Therefore, physiotherapy is a critical component of treatment to enhance muscle strength, facilitate early and rapid recovery, and manage the clinical manifestations of the condition.

Transnasal Endoscopic Treatment of Tension Pneumocephalus Caused by Posttraumatic or Iatrogenic Ethmoidal Damage

Background

Tension pneumocephalus is a neurosurgical emergency caused by progressive accumulation of air in the intracranial spaces mediated by a valve mechanism. Tension pneumocephalus usually presents with headaches, reduced consciousness, and even death. One of the most common causes is an ethmoidal defect resulted by nasal surgery or facial traumas.

Methods

A literature review about tension pneumocephalus resulting from ethmoidal damages was performed. Surgery strategies included decompression by frontal burr holes and multilayer repair of the ethmoidal defect. In this paper, an endoscopic technique that exploits the ethmoidal defect to decompress the intracranial spaces and to resolve tension pneumocephalus with fewer complications and shorter hospitalization in comparison to frontal craniotomy is proposed.

Conclusion

The proposed endonasal endoscopic technique could be effectively used as a first-line treatment for symptomatic tension pneumocephalus caused by posttraumatic or iatrogenic ethmoidal defect.

From Eardrum to Cranium: Pneumocephalus Secondary to Acute Otitis Media

Pneumocephalus, or air entrapment within the cranium, is a rare but dangerous condition with a variety of causes, including trauma, surgery, or predisposing infection. Trauma is the most common etiology, as fractures provide easy access for air to become entrapped in the cranium. However, access such as via the central nervous system with leak exists. Though not as common as traumatic pneumocephalus, pneumocephalus secondary to infection is a dangerous condition. The literature is sparse on this example of ear-nose-throat infection, making it difficult to form and ascertain guidelines for the management of infectious pneumocephalus and its complications. A 58-year-old man with a history of hypertension, obesity, type 2 diabetes mellitus, and obstructive sleep apnea who presented with a complicated case of acute otitis media associated with subdural empyema, pneumocephalus, and group A Streptococcus is presented in this case report. We describe the course of his hospital stay, management, and current infectious disease guidelines. Given the paucity of cases of infectious pneumocephalus secondary to otitis media, we aim to provide further representation for this important illness as well as encourage the use of a multimodal team of providers. In our case, it was necessary to involve the ear-nose-throat specialist as well as infectious disease and neurocritical care services.

Pneumocephalus secondary to epidural analgesia: a case report

INTRODUCTION

Epidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a rare and potentially serious complication of epidural anesthesia, which is most often caused by accidental puncture of the dura with the introduction of air into intrathecal space.

CASE PRESENTATION

We present the case of a 19-year-old Hispanic female who developed a severe frontal headache and neck pain eight hours following epidural catheter placement to deliver analgesia during labor. Physical examination was within normal limits without any neurological deficits. Computed tomography of the head and neck would later demonstrate small to moderate amounts of pneumocephalus, predominantly within the frontal horn of the lateral ventricles, and a moderate amount of air within the spinal canal. She was treated conservatively with analgesia. Though headache recurred after discharge, repeat imaging showed improvement in the volume of pneumocephalus and conservative management was continued.

CONCLUSIONS

Although a rare complication and an uncommon cause of headache following epidural anesthesia, a high index of suspicion must remain for pneumocephalus as it may cause significant morbidity and, in some cases, be potentially life-threatening.

A Rare Case of Tension Pneumocephalus with Spontaneous CSF Rhinorrhea Managed by Endoscopic Trans-Sphenoidal CSF Leak Repair

Tension Pneumocephalus and spontaneous CSF rhinorrhea are very rare associations in clinical practice. We report a case of 65 years old male with clear rhinorrhea, severe frontal headache, vomiting and lethargy for a week. MR Cisternography and CT Paranasal sinuses showed significant Tension Pneumocephalus with defect in the posterior wall of sphenoid sinus and CSF pooling in the sphenoid sinus. Endoscopic trans-sphenoidal CSF leak repair was done without any delay followed by complete resolution of Tension Pneumocephalus with in 4 post op days. Prompt precise diagnosis and early intervention of Tension Pneumocephalus is vital to avoid neurological complications.

Posttraumatic Tension Pneumocephalus Causing Atropine-Resistant Bradycardia

Pneumocephalus is a serious complication following brain trauma. Tension pneumocephalus (TP) is entrapment of a large volume of air in the cranial vault causing mass effect on the brain parenchyma. It is the intracranial counterpart of tension pneumothorax and if neglected, can be life threatening. TP should be timely differentiated from benign pneumocephalus owing to its various nonspecific and lethal complications. Our patient is a 37-year-old male with a history of road traffic accident who presented to our hospital with headache and nasal discharge for the last two days. Computed tomography showed multiple skull fractures and extensive pneumocephalus. His preoperative heart rate was 38 beats per minute that was resistant to pharmacological interventions and required a temporary pacemaker for surgery. He underwent uneventful craniotomy for dura repair and was discharged home with no neurological deficit.

Extensive tension pneumocephalus presented in the setting of a challenging etiology

Background

Pneumocephalus (PNC) is a well-described consequence in postoperative settings and skull fractures that is usually self-limiting. It can get complicated into tension PNC on some rare occasions, leading to an intracranial mass effect. PNC was also reported after unintentional dural puncture throughout the epidural anesthesia process. However, tension PNC resulting from epidural anesthesia procedures is an extremely rare outcome that implies urgent intervention to relieve the tension within the brain. Here, we report a case of an extensive tension intraventricular PNC 2 days following an epidural anesthesia procedure for a femur fixation surgery.

Case Description

A 23-year-old male presented to the emergency department with basal skull fractures and a femur fracture due to a motorcycle accident. His skull base fracture was managed conservatively then he underwent a femur fixation procedure under epidural anesthesia. Two days after, he developed a severe headache with a disturbed level of consciousness. Computed tomography of the brain revealed an extensive PNC that involved all the subarachnoid spaces down to the cervical region and compressing the cerebellum, which was not found in the initial imaging. The patient's status improved after the twist-drill burr-hole evacuation of air under the water seal.

Conclusion

Extensive tension PNC can occur after traumatic brain injury, especially after epidural anesthesia. Such cases should gain high focus because they may differ from simple PNC regarding diagnosis, treatment, and follow-up.

Endoscopic Endonasal Eustachian Tube Obliteration as a Treatment for Tension Pneumocephalus After Translabyrinthine Resection of Vestibular Schwannoma

OBJECTIVE

Cerebrospinal fluid leak and pneumocephalus are rare but potentially devastating complications associated with translabyrinthine resection of cerebellopontine angle masses. Persistent pneumocephalus despite proximal eustachian tube (ET) obliteration is rare. We describe, to our knowledge, the first report of successful management of tension pneumocephalus by endoscopic endonasal ET obliteration using a novel V-loc (Covidien; Medtronic, Minneapolis, MN) suture technique.

PATIENTS

A 63-year-old man presented with altered mental status 10 months after translabyrinthine excision of a left cerebellopontine angle vestibular schwannoma measuring 2.8 × 2.9 × 3.3 cm. Computed tomography demonstrated diffuse ventriculomegaly and new pneumocephalus along the right frontal lobe, lateral ventricles, and third ventricle, and air within the left translabyrinthine resection cavity.

INTERVENTION

The patient underwent left-sided endoscopic endonasal ET obliteration using 2-0, 9-inch V-loc suture.

MAIN OUTCOME MEASURE

Postoperatively, the patient's mental status improved with a decrease in size of the lateral and third ventricles on computed tomography.

CONCLUSION

Endoscopic endonasal ET obliteration, a technique previously applied to recalcitrant cerebrospinal fluid leaks, is a safe and reasonable alternative to reentering the original surgical site for patients with pneumocephalus after lateral skull base surgery. Utilizing a V-loc suture for this technique instead of a traditional suture may improve procedural ease and speed.

Pneumocephalus and headache following craniotomy during the immediate postoperative period

Background

Pneumocephalus may be responsible for post-craniotomy headache but is easily overlooked in the clinical situation. In the present study, the relationship between the amount of intracranial air and post-craniotomy headache was investigated.

Methods

A retrospective observational study was performed on 79 patients who underwent minimal invasive craniotomy for unruptured cerebral aneurysms. Those who had undergone previous neurosurgery, neurological deficit before and after surgery were excluded The amount of air in the cranial cavity was measured using brain computed tomography (CT) taken within 6 h after surgery. To measure the degree of pain due to intracranial air, daily and total analgesic administration amount were used as a pain index. Correlation between intracranial air volume and total consumption of analgesic during hospitalization was tested using Spearman rank correlation coefficients. Receiver operating characteristics (ROC) analysis was used to determine the amount of air associated with increased analgesic consumption over 72 h postoperatively.

Results

The mean amount of intracranial air was 15.6 ± 9.1 mL. Total administration of parenteral and oral analgesics frequency were 6.5 ± 4.5, 13.2 ± 7.9 respectively. A statically significant correlation was observed between daily and total parenteral analgesic consumption after surgery and the amount of intracranial air at followed-up brain CT postoperatively within 24 h (r = 0.69, p < 0.001), within 48 h (r = 0.68, p < 0.001), and total duration after surgery (r = 0.84, p < 0.001). The optimal cut-off value of 12.14 mL of intracranial air predicts the use of parenteral analgesics over 72 h after surgery.

Conclusions

Pneumocephalus may be a causative factor for post-craniotomy pain and headache with surgical injuries.

Pneumocephalus after subcutaneous emphysema

Background:

Pneumocephalus is the presence of air in the intracranial cavity secondary to communication with the extracranial compartment. It occurs spontaneously, after trauma, or after a cranial surgery.

Case Description:

A 62-year-old female, a known case of diabetes mellitus, presented to our emergency department with a sudden thunderclap headache. She was diagnosed with subarachnoid hemorrhage secondary to ruptured anterior communicating artery aneurysm. Twenty days later, she developed pneumonia and subsequently had a cardiac arrest. She was revived after 26 min of cardiopulmonary resuscitation. She developed pneumothorax requiring a chest tube insertion. After the first trial, she developed a diffuse subcutaneous emphysema, and the chest tube was reinserted. Afterward, she became unresponsive with dilated pupils. A computed tomography (CT) scan of the brain showed a diffuse subcutaneous emphysema reaching up to the face with air around the ventriculoperitoneal shunt distal catheter and extending through the burr hole to the ventricles causing pneumocephalus. There was no evidence of skull base fractures on brain CT. Unfortunately, the patient did not recover and passed away 3 days later.

Conclusion:

This report describes the presentation and radiological findings of an interesting case of pneumocephalus following iatrogenic diffuse subcutaneous emphysema. It aims to increase the emphasis on early anticipation of such rare complication after subcutaneous emphysema.

Application of the subdural evacuating port system for the drainage of postoperative tension pneumocephalus: A technical note

Background:

Tension pneumocephalus is a neurosurgical emergency requiring prompt intervention. A variety of either temporizing or definitive methods was previously described as part of its management. Here, we report on an off-label use of a bed-side device and the subdural evacuating port system (SEPS)™ for the treatment of tension pneumocephalus.

Methods:

The SEPS™ (Medtronic Dublin, Ireland) is a minimally invasive tool that is indicated for the removal of chronic or subacute subdural hematomas and at the patient’s bedside. We describe the use of this system to evacuate tension pneumocephalus.

Results:

A 44-year-old patient operated in our institution was presented with sudden obtundation 4 days post resection of esthesioneuroblastoma. Imaging confirmed a significant tension pneumocephalus. Immediate bedside decompression using a SEPS bolt placed frontally was performed, achieving rapid evacuation and patient regained consciousness. A definitive skull base reconstruction was done at the operating room at a later stage.

Conclusion:

The SEPS™, well-known for evacuation of CSDH, can be potentially used as a bed-side tool to effectively treat mass effect created by tension pneumocephalus. As a readily-available and commercially used device, it can provide a simple and standard toolkit suitable for an emergent temporizing procedure.

Tension pneumocephalus following endoscopic resection of a mediastinal thoracic spinal tumor: A case report

BACKGROUND

Pneumocephalus is a rare complication presenting in the postoperative period of a thoracoscopic operation. We report a case in which tension pneumocephalus occurred after thoracoscopic resection as well as the subsequent approach of surgical management.

CASE SUMMARY

A 66-year-old man who received thoracoscopic resection to remove an intrathoracic, posterior mediastinal, dumbbell-shaped, pathology-proven neurogenic tumor. The patient then reported experiencing progressively severe headaches, especially when in an upright position. A brain computed tomography scan at a local hospital disclosed extensive pneumocephalus. Revision surgery for resection of the pseudomeningocele and repair of the cerebrospinal fluid leakage was thus arranged for the patient. During the operation, we traced the cerebrospinal fluid leakage and found that it might have derived from incomplete endoscopic clipping around the tumor stump near the dural sac at the T3 level. After that, we wrapped and sealed all the possible origins of the leakage with autologous fat, tissue glue, gelfoam, and duraseal layer by layer. The patient recovered well, and the computed tomography images showed resolution of the pneumocephalus.

CONCLUSION

This report and literature review indicated that the risk of developing a tension pneumocephalus cannot be ignored and should be monitored carefully after thoracoscopic tumor resection.

Air travel with pneumocephalus: a systematic review

INTRODUCTION

Concerns arise when patients with pneumocephalus engage in air travel. How hypobaric cabin pressure affects intracranial air is largely unclear. A widespread concern is that the intracranial volume could relevantly expand during flight and lead to elevated intracranial pressure. The aim of this systematic review was to identify and summarise models and case reports with confirmed pre-flight pneumocephalus.

METHODS

The terms (pneumocephalus OR intracranial air) AND (flying OR fly OR travel OR air transport OR aircraft) were used to search the database PubMed on 30 November 2021. This search returned 144 results. To be included, a paper needed to fulfil each of the following criteria: (i) peer-reviewed publication of case reports, surveys, simulations or laboratory experiments that focussed on air travel with pre-existing pneumocephalus; (ii) available in full text.

RESULTS

Thirteen studies met the inclusion criteria after title or abstract screening. We additionally identified five more articles when reviewing the references. A notion that repeatedly surfaced is that any air contained within the neurocranium increases in volume at higher altitude, much like any extracranial gas, potentially resulting in tension pneumocephalus or increased intracranial pressure.

DISCUSSION

Relatively conservative thresholds for patients flying with pneumocephalus are suggested based on models where the intracranial air equilibrates with cabin pressure, although intracranial air in a confined space would be surrounded by the intracranial pressure. There is a discrepancy between the models and case presentations in that we found no reports of permanent or transient decompensation secondary to a pre-existing pneumocephalus during air travel. Nevertheless, the quality of examination varies and clinicians might tend to refrain from reporting adverse events. We identified a persistent extracranial to intracranial fistulous process in multiple cases with newly diagnosed pneumocephalus after flight. Finally, we summarised management principles to avoid complications from pneumocephalus during air travel and argue that a patient-specific understanding of the pathophysiology and time course of the pneumocephalus are potentially more important than its volume.

Quadriparesis Due to Delayed Tension Pneumoventricle

INTRODUCTION

Although pneumocephalus is very common after intracranial or spinal surgeries, pneumoventricle is uncommon. Tension pneumoventricle (tPV) occurs when air in the ventricles expands to cause neurological deficits or mass effect. It is usually seen with a combination of a ball-valve defect postoperatively that sucks in air and a ventriculoperitoneal shunt that drains cerebrospinal fluid and allows the ingress of air.

CASE REPORT

A young man developed delayed tPV after surgery for craniopharyngioma. He required multiple surgeries and occlusion of the ventriculoperitoneal shunt before the tPV resolved.

CONCLUSIONS

The probable mechanisms of tPV and the importance of early recognition and treatment are discussed. A review of the literature of this uncommon entity has also been performed.

Pneumocephalus Following an Accidental Dural Puncture, Treated Using Hyperbaric Oxygen Therapy. A Case Report

Introduction

Neuraxial techniques, including epidural anaesthesia, are often used for perioperative pain control and are generally safe. However, both transient, mild and even severe, life-threatening neurologic complications can occur.

Case presentation

A seventy-eight-year-old man was admitted to the hospital for a radical nephrectomy plus transurethral resection due to kidney and bladder cancer. During the epidural exploration, an accidental dural puncture was noted. This was followed by the patient complaining of an intense headache. The epidural catheter was placed in a different location, and surgery was performed uneventfully. The patient presented with confusion, agitation, vertical nystagmus, vision loss, and paraparesis about two hours later. The epidural levobupivacaine and morphine infusion were stopped, followed by motor block resolution. A computerized head-tomography scan showed extra-axial multiple air spots involving the frontal and temporal lobes. Emergent hyperbaric oxygen therapy was commenced. After a single session, there was complete resolution of all symptoms and a marked reduction in the number and volume of the extra-axial air visible on the CT scan.

Conclusions

Although rare, pneumocephalus is a well-recognized complication of a dural puncture. Its rapid recognition in a patient with new-onset neurological symptoms and early treatment with hyperbaric oxygen therapy allows rapid clinical and imaging resolution and an improved prognosis.

A practical guide to patient position and complication management in neurosurgery: a systematic qualitative review

PURPOSE

Adequate patient positioning is of paramount importance in neurosurgery. Complications related to the position are common and make up for more than 16% of the claims towards anaesthesiologists and neurosurgeons. This paper aims to provide the anaesthesiologist with a practical guide to avoid common pitfalls related to the patient positioning process.

METHOD

We performed a systematic review of the medical literature for the identification, screening, and inclusion of articles. The bibliographic search was conducted on June 1st, 2021 by two of the authors. In this review, we included articles indexed by MEDLINE, Cochrane Library, or Google Scholar.

RESULTS

We retrieved a total of 5706 unique papers from our initial search. However, after the initial screening, 5363 papers were removed is not related to our research leaving a total of 343 papers. We examined the full text of all the 343 articles including 68 of them in the final qualitative analysis.

DISCUSSION

In this review we examine the most common neurosurgical positions: supine, sitting, lateral, park-bench, prone, jack-knife, and knee-chest. For each of them, the proper positioning and related complications are described. Particular attention is given to the prevention and management of these complications, providing a practical guide for clinicians.

MRI diagnosis of spontaneous intraventricular tension-pneumocephalus in a 10-month-old male Saarloos Wolfdog

A 10-month-old male Saarloos Wolfdog was presented with a history of multiple neurologic deficits that had acutely progressed. Neurologic examination findings localized signs to the cerebrum and brainstem. Magnetic resonance imaging revealed markedly enlarged and gas-filled lateral ventricles with a mass effect leading to cerebellar herniation. A right-sided defect of the cribriform plate with a dysplastic ethmoturbinate was identified as the inlet of air and origin of the intraventricular tension pneumocephalus. Surgical findings were consistent with a ruptured, congenital, nasal meningocele.

A rare case of Escherichia coli and Rhizopus sinusitis complicated with pneumocephalus, E. coli psoas abscess and sepsis

Sinusitis is a common ailment a clinician comes across in their day-to-day practice. Simple as it may sound, it may become a very debilitating condition depending on the comorbidities of the patient and the organism involved. Rhizopus and Escherichia coli are less common organisms to affect the sinuses, but they are more common in immunocompromised patients such as patients with uncontrolled diabetes. Rhizopus can be a very debilitating infection as it erodes into the bone and blood vessels resulting in tissue necrosis. However, coinfection of both of these organisms is a very rare occurrence. Psoas abscess is also a less common infection in the immunocompetent patients but it is more common among the immunocompromised patients. It is extremely rare for both of these organisms to cause sinusitis in one patient, and for E. coli to simultaneously infect two different sites in the same patient. We report a case where a diabetic patient who had E. coli and Rhizopus coinfected sinusitis with simultaneous E. coli psoas abscess was successfully managed. The Rhizopus was treated with liposomal amphotericin B for 16 weeks while E. coli was treated with IV Meropenum. Furthermore, pneumocephalus is a condition that usually occurs following head trauma but the patient we are reporting developed pneumocephalus following Rhizopus sinusitis, which was treated with high-flow oxygen.

Pneumocephalus secondary to a spinal surgery: A literature review and a case report

Introduction

We report a case of pneumocephalus, which is identified as the presence of air in the cranial cavity and is a rare complication after spinal surgeries, in addition to a literature review of similarly reported cases.

Case presentation

The patient is a 63-year-old male who developed pneumocephalus after undergoing a minimally invasive left side decompression at L3-L4 with left L4 foraminotomy even though there were no signs of dural tears or Cerebrospinal Fluid (CSF) leaks. After the diagnosis of pneumocephalus using brain Magnetic Resonance Imaging (MRI), the patient was treated conservatively and was discharged after 3 weeks without developing further complications.

Discussion

Pneumocephalus is defined as an abnormal accumulation of air within the cranial cavity. It can occur due to a variety of causes but rarely due to gas forming bacteria. Many theories are suggested concerning the pathophysiology of pneumocephalus, the inverted bottle theory, the ball valve theory, the Nitrous Oxide (N₂O) theory, and as we outweigh in our case, gas forming bacteria theory. Pneumocephalus can be treated surgically, nevertheless, conservative management methods of such cases are usually followed.

Conclusion

The aim of this study is to draw further attention to the management and diagnosis of such surgical complication. A more extended research is needed to provide a full comprehensive approach to deal with this problem if faced in the future. To the best of our knowledge, this study reports the first pneumocephalus case induced by a postoperative bacterial infection in the global English based medical literature.

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Pneumocephalus caused by gas forming infection in the spine is a rare complication after spinal surgery.

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Unexplained headache spinal surgeries should raise suspicion toward pneumocephalus.

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There are many theories regarding the development of pneumocephalus, each one need specific attention.

Traumatic Pneumocephalus Without Skull Fracture From a High-Voltage Electrical Injury

Pneumocephalus, the presence of intracranial air, most commonly occurs secondary to a traumatic injury. Patients with simple pneumocephalus often present with nonspecific symptoms or with headaches. These patients may have little to no clinically relevant physical examination findings and can be managed conservatively. Tension pneumocephalus can present more acutely as a neurosurgical emergency. On physical examination, patients can present with neurologic deficits or papilledema. Computed tomography is the imaging modality of choice to detect intracranial air. We present a novel case of a simple pneumocephalus in the setting of a high-voltage electrical injury without evidence of displaced skull fracture or dural violation. The identification of unanticipated air within the cranial vault should prompt emergency physicians to determine its etiology which can guide treatment and disposition.

Fatal Acute Pneumocephalus after Bilateral Drainage for Chronic Subdural Hematomas: Case Report

BACKGROUND

 Pneumocephalus is a well-known complication in the surgical treatment of chronic subdural hematomas; however, its influence remains controversial. The amount of subdural air may vary, and it may cause worsening of symptoms, increase reoccurrence rates, and worsen the outcomes. Lethal outcome following acute onset of massive pneumocephalus was not previously reported.

CASE REPORT

 An 81-year-old man with bilateral hematomas underwent surgery under local anesthesia. Both hematomas were approached in the same surgery, and the drains were placed subdurally. After initial improvement, severe hypertension developed, followed by vital function and neurologic deterioration. Massive pneumocephalus with subarachnoid and contralateral intracerebral hemorrhage was revealed, causing a severe midsagittal shift. Emergency irrigation to evacuate subdural air was performed. However, there was no improvement. Further computed tomography confirmed subdural air collection, but it also revealed hemorrhage progression and intraventricular propagation. No further surgery was indicated.

CONCLUSION

 Pneumocephalus is an underestimated but potentially devastating complication. Both intraoperative avoidance and postoperative prevention should be utilized to avoid subdural air ingress, and thus evade potentially fatal complications.

Pneumocephalus with meningitis secondary to an old traumatic anterior cranial fossa defect

We report a case of a 30-year-old man who presented with altered mental status, fever, headache and vomiting for 3 days. An initial CT scan of the brain revealed the presence of pneumocephalus with a bony defect in the anterior cranial fossa. The pneumocephalus was not explained initially and the patient was re-examined for any signs of trauma to the face, and a review of the history revealed a series of three traumatic events months prior to this illness. Further laboratory studies revealed Streptococcus pneumoniae in the blood and bacterial meningitis. He was treated with antibiotics and was later taken up for endoscopic repair of the skull base defect. This case highlights the importance of recognising post-traumatic pneumocephalus with superimposed meningitis and sepsis months after a traumatic event to the skull base.

Pneumocephalus in thoracoabdominal aortic aneurysm repair after lumbar drain removal and blood patch

Lumbar spinal drain use during thoracic and thoracoabdominal aortic aneurysm repair has reduced the incidence of ischemic spinal cord injury with relatively low risk. We report a case of pneumocephalus in a 55-year-old woman who had undergone open repair of a 6.7-cm type IV thoracoabdominal aortic aneurysm. After lumbar spinal drain removal, she developed a postdural headache, which was subsequently treated with blood patch placement. After discharge, she had presented with transient headaches, perioral numbness, and left-hand weakness. Computed tomography revealed intraventricular gas within the lateral ventricles. Pneumocephalus is an exceedingly rare and potentially dangerous complication of lumbar spinal drains and blood patch placement.

Tension pneumoventricle: Reversible cause for aphasia

Pneumocephalus is air in the cranium commonly seen in postcraniotomy and in head injury patients. When this air causes an increase in intracranial pressure leading to neurological deterioration, it is called tension pneumocephalus. Similarly, intraventricular air causing compression on vital centers and increasing intracranial pressure is called tension pneumoventricle, and this causes expressive aphasia, which is rarely described in the literature. This study reported a case of a traumatic cerebrospinal fluid (CSF) leak leading to tension pneumoventricle and aphasia.

Case: A young male patient sustained severe head injury and had extradural hematoma (EDH) and multiple skull and skull base fractures. EDH was drained, and he recovered and was discharged with a Glasgow coma scale score of 15. He presented to neurosurgical outpatient with CSF leak, aphasia, and loss of bowel and bladder control for a duration of three days. Computed tomography brain scan showed tension pneumoventricles, and he was started on conservative management. His general condition deteriorated, and the next day, his pupils became unequal, and Glasgow coma scale (GCS) dropped to 8/15. He was immediately taken to theater, and the air was aspirated from the ventricles, and an external ventricular drain was inserted. The patient woke up in the immediate postoperative period and started talking normally by day four.

Conclusion: Tension pneumoventricles should be considered a cause of aphasia. Immediate intervention and reduction of intracranial pressure are crucial to reverse neurological abnormality and improve patient's outcome.

Don't Forget Rare Causes of Postpartum Headache! Cases Report and Literature Review

Headache is a common finding in the postpartum period, caused by a spectrum of different conditions. Most headaches in the postpartum period are self-limiting and benign in etiology, but there are some potentially serious causes to be considered. We disclose two cases of postpartum headache, initially considered as post-dural puncture headache (PDPH), that evolved into a harmful condition and showed that an expanded differential diagnosis for headache in the postpartum is mandatory, requiring a high level of attention from health professionals. In fact, a careful examination of the medical history, physical examination, and the recognition for the need for early neuroradiological imaging should increase diagnostic accuracy.

An unusual case of spontaneous nontraumatic pneumocephalus in the setting of remote craniofacial surgery

BACKGROUND

Pneumocephalus is an uncommon pathology that typically follows head trauma, neurosurgery, or skull base tumors. Rarely, cases of spontaneous pneumocephalus can occur, most often in the setting of barotrauma.

CASE DESCRIPTION

We describe a rare case of spontaneous pneumocephalus in the absence of barotrauma in a 31-year-old male who presented with a headache and a normal neurologic exam. Imaging revealed subarachnoid and subdural pneumocephalus. The patient underwent surgical exploration, revealing an ethmoid bone defect caused by encroachment of material from a remote reconstructive surgery of the left orbit, which was subsequently repaired.

CONCLUSION

Although rare, spontaneous pneumocephalus should be considered even in the absence of clinical neurologic findings or barotrauma, in patients with previous cranial surgery and unexplained headaches.

Delayed post-traumatic Tension Hydropneumocephalus; a Case Report of Conservative Treatment

Pneumocephalus refers to the presence of air in the cranial cavity. Trauma is the most common cause of acquired pneumocephalus. Tension pneumocephalus occurs when intracranial accumulation of air causes high pressure on the brain as compared to extracranial pressure. Tension pneumocephalus is usually acute, and causes neurological symptoms, and its delayed form rarely occurs. A 12-year-old girl presented with a headache, lethargy, mild fever, and nausea from two days before admission to emergency department of Shahid Rajaei Hospital, Qazvin, Iran. The patient had a history of head trauma in a driving accident six weeks before and had undergone brain computed tomography (CT) scan in another centre, which had revealed no sign of pneumocephalus. The patient had been treated for one week and had been discharged in good general condition.

Considering her reduced consciousness, the patient underwent brain CT scan again in our centre. CT scan revealed tension hydropneumocephalus. The patient was transferred to the intensive care unit (ICU) for treatment. Considering the trend of her recovery, the patient was a candidate for conservative non-surgical therapy based on the in-charge neurosurgery specialist’s decision. The patient reported no complications during the six-month follow-up. Delayed tension pneumocephalus is among neurosurgery emergencies usually treated with early surgical intervention and dura defect restoration, but this patient received non-surgical treatment without any serious problem during the six-month follow-up.

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.

Complications in Skull Base Surgery and Subsequent Repair

Over the past several decades, endoscopic sinus surgery has revolutionized the approach to skull base surgery. Open skull base approaches remain a viable option for advanced skull base tumors. Complications have gone down with increased reliability of vascularized tissue transfer. In this article, the authors explore the various complications that can present following skull base surgery and review the approaches for repair when such issues are encountered.

Pneumocephalus causing oculomotor nerve palsy: A case report

Background:

Pneumocephalus, the presence of gas or air within the intracranial cavity, is a common finding after cranial procedures, though patients often remain asymptomatic. Rare cases of cranial nerve palsies in patients with pneumocephalus have been previously reported. However, only two prior reports document direct unilateral compression of the third cranial nerve secondary to pneumocephalus, resulting in an isolated deficit.

Case Description:

A 26-year-old male developed a unilateral oculomotor (III) nerve palsy after repair of a cerebrospinal fluid leak. The pneumocephalus was treated with a combination of an epidural drain, external ventricular drain (EVD), and high-flow oxygen. Following treatment, repeat computed tomography imaging of the head demonstrated that the pneumocephalus was progressively resorbed and the patient’s deficit resolved.

Conclusion:

In rare cases, isolated cranial nerve palsies, specifically of the third cranial nerve, can result from pneumocephalus following cranial procedures. Acute cranial nerve palsy secondary to pneumocephalus will often resolve without intervention as the air is resorbed, but direct decompression with an epidural drain and an EVD may expedite the resolution of deficits.

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

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.