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Martinez-Nunez AE, Wong JK, Hilliard JD, Foote KD, Okun MS. Preventing Shift from Pneumocephalus During Deep Brain Stimulation Surgery: Don't Give Up the 'Fork in the Brain'. Tremor Other Hyperkinet Mov (N Y) 2024; 14:18. [PMID: 38617832 PMCID: PMC11011943 DOI: 10.5334/tohm.873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/23/2024] [Indexed: 04/16/2024] Open
Abstract
Clinical vignette We present the case of a patient who developed intra-operative pneumocephalus during left globus pallidus internus deep brain stimulation (DBS) placement for Parkinson's disease (PD). Microelectrode recording (MER) revealed that we were anterior and lateral to the intended target. Clinical dilemma Clinically, we suspected brain shift from pneumocephalus. Removal of the guide-tube for readjustment of the brain target would have resulted in the introduction of movement resulting from brain shift and from displacement from the planned trajectory. Clinical solution We elected to leave the guide-tube cannula in place and to pass the final DBS lead into a channel that was located posterior-medially from the center microelectrode pass. Gap in knowledge Surgical techniques which can be employed to minimize brain shift in the operating room setting are critical for reduction in variation of the final DBS lead placement. Pneumocephalus after dural opening is one potential cause of brain shift. The recognition that the removal of a guide-tube cannula could worsen brain shift creates an opportunity for an intraoperative team to maintain the advantage of the 'fork' in the brain provided by the initial procedure's requirement of guide-tube placement.
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Affiliation(s)
- Alfonso Enrique Martinez-Nunez
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Disease, University of Florida, Gainesville, FL, US
| | - Joshua K. Wong
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Disease, University of Florida, Gainesville, FL, US
| | - Justin D. Hilliard
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Disease, University of Florida, Gainesville, FL, US
| | - Kelly D. Foote
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Disease, University of Florida, Gainesville, FL, US
| | - Michael S. Okun
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Disease, University of Florida, Gainesville, FL, US
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Mallik D, Chandrashekhar N, Rai AK, Dhingra S, Arora G, Gandhi S, Scalia G, Chaurasia B. Osteoblastoma of the frontal sinus: A rare case presenting with seizures and pneumocephalus. Clin Case Rep 2024; 12:e8776. [PMID: 38623357 PMCID: PMC11017458 DOI: 10.1002/ccr3.8776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 04/17/2024] Open
Abstract
Key Clinical Message Osteoblastoma of the frontal sinus, although rare, can manifest with seizures and pneumocephalus, underscoring the importance of thorough evaluation and complete surgical excision to prevent serious complications and ensure optimal patient outcomes. Abstract Osteoblastoma is an infrequent bone tumor, with origins typically in the vertebrae and long bones. While craniofacial involvement is rare, it may occur in regions such as the paranasal sinuses. We present a case of osteoblastoma located in the frontal sinus, an exceptionally uncommon site, resulting in seizures secondary to pneumocephalus. A 21-year-old male presented with a generalized tonic-clonic seizure and postictal confusion. Imaging studies revealed a well-defined lesion in the left frontal sinus causing cortical breach, destruction of the posterior wall, and pneumocephalus. A total surgical excision was performed through bifrontal craniotomy. Histopathological analysis confirmed the diagnosis of osteoblastoma. Postoperative recovery was uneventful, with a follow-up CT scan showing complete lesion excision. Osteoblastomas, especially in the cranial sinuses, are rare entities that may present asymptomatically but can lead to severe complications. The risk of recurrence underscores the importance of complete surgical resection for optimal patient outcomes.
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Affiliation(s)
- Dattatraya Mallik
- Department of NeurosurgerySakra World HospitalBengaluruKarnatakaIndia
| | | | | | - Saransh Dhingra
- Department of NeurosurgerySakra World HospitalBengaluruKarnatakaIndia
| | - Gaurav Arora
- Department of NeurosurgerySakra World HospitalBengaluruKarnatakaIndia
| | - Sapan Gandhi
- Department of NeurosurgerySakra World HospitalBengaluruKarnatakaIndia
| | - Gianluca Scalia
- Neurosurgery Unit, Department of Head and Neck SurgeryGaribaldi HospitalCataniaItaly
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Alanazy S, Cho SI. Extensive Pneumocephalus Secondary to Petrous Bone Cholesteatoma. Ear Nose Throat J 2024; 103:248-251. [PMID: 34587824 DOI: 10.1177/01455613211048966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Sultan Alanazy
- Department of Otolaryngology-Head and Neck Surgery, Chosun University College of Medicine, Gwangju, South Korea
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Unaizah College of Medicine and Medical Sciences, Qassim University, Buraydah, Saudi Arabia
| | - Sung Il Cho
- Department of Otolaryngology-Head and Neck Surgery, Chosun University College of Medicine, Gwangju, South Korea
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Umekawa M, Hasegawa H, Shinya Y, Shin M, Saito N. Incidence of and risk factors for chronic subdural hematoma after endoscopic endonasal surgery: quantitative analysis of pneumocephalus. J Neurosurg 2024:1-7. [PMID: 38457806 DOI: 10.3171/2024.1.jns231953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/09/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is known to occur after endoscopic endonasal surgery (EES); however, the detailed clinical picture remains unclear. In this study, the authors aimed to examine the incidence of and risk factors for post-EES CSDH, with a focus on the quantitative evaluation of postoperative pneumocephalus. METHODS The authors retrospectively collected data on consecutive patients who, between November 2016 and December 2022, had undergone EES during which intraoperative cerebrospinal fluid (CSF) leakage occurred. Using CT images obtained immediately after surgery (CT0), the authors measured the extent of pneumocephalus in detail. The locations of pneumocephalus were divided into two groups: remote and local. Remote pneumocephalus was further subdivided into convexity and ventricular. The incidence of post-EES CSDH was calculated, and its risk factors were analyzed. RESULTS Among the 159 EES patients included in the study, Esposito grade 1, 2, and 3 intraoperative CSF leakage was confirmed in 22 (14%), 27 (17%), and 110 (69%) patients, respectively. CSDH occurred in 6 patients (3.8%). One patient (0.6%) required unilateral burr hole surgery, whereas the hematomas spontaneously disappeared in the others. All CSDHs occurred in patients with Esposito grade 3 CSF leakage and convexity pneumocephalus on CT0. In the multivariate analysis of 149 sides with convexity pneumocephalus on CT0, the product of the diameter and the thickness of convexity pneumocephalus on CT0 was significantly associated with subsequent CSDH (OR 1.21, 95% CI 1.06-1.38, p = 0.004). Using a cutoff value of 10 cm2, CSDH development could be predicted with a sensitivity of 0.82 and specificity of 0.74. CONCLUSIONS The incidence of post-EES CSDH is acceptably low, and surgery is rarely required. Patients with extensive convexity pneumocephalus on immediate postoperative CT are prone to develop CSDH and thus should be carefully monitored.
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Affiliation(s)
- Motoyuki Umekawa
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Hasegawa
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuki Shinya
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Masahiro Shin
- 3Department of Neurosurgery, Teikyo University Hospital, Tokyo, Japan
| | - Nobuhito Saito
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Candy NG, Wu KC, Finger G, VanKoevering K, Prevedello DM. Management of frontoethmoidal osteoma causing pneumocephalus and cerebrospinal fluid leakage with minimally invasive techniques: illustrative cases. J Neurosurg Case Lessons 2024; 7:CASE23699. [PMID: 38315987 PMCID: PMC10849144 DOI: 10.3171/case23699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Osteoid osteoma is a common benign bone tumor frequently seen in the frontoethmoid region. However, involvement of the skull base is rare, with few cases previously reported. OBSERVATIONS The authors report two cases of spontaneous, symptomatic frontoethmoidal osteoma: one presented with neurological deficit secondary to tension pneumocephalus and the other with cerebrospinal fluid leakage. The first case was managed with a transfrontal sinus craniotomy and pneumocephalus decompression with osteoma resection and skull base reconstruction. The second case was managed with a uninaral endoscopic endonasal approach to the anterior skull base with osteoma resection and reconstruction. LESSONS Given the paucity of cases with associated tension pneumocephalus described in the literature, it was relevant to describe the authors' experience with surgical decision-making and the expected outcomes among patients with this pathology when using minimally invasive techniques.
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Affiliation(s)
- Nicholas G Candy
- 1Department of Surgery-Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kyle C Wu
- 2Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Guilherme Finger
- 2Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Kyle VanKoevering
- 3Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Ohio
| | - Daniel M Prevedello
- 2Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio; and
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Bindu B, Singh GP, Pandia MP. Effect of nitrous oxide on clinical outcome in patients undergoing cerebellopontine tumor surgery under sevoflurane anesthesia: a randomized controlled trial. Med Gas Res 2024; 14:26-32. [PMID: 37721252 DOI: 10.4103/2045-9912.351105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Nitrous oxide (N2O) is a unique anesthetic agent that has both advantages and disadvantages, especially in neurosurgical patients. Various studies evaluating the use of N2O in different surgical populations have been inconclusive so far. In this prospective, single-blinded, randomized study, 50 patients of either sex, aged 18-60 years, were enrolled and randomly allocated into N2O or N2O free group. Data including demographics, intraoperative vitals, blood gases, intravenous fluids, anesthetic drug consumption, brain condition, emergence and recovery time, duration of surgery and anesthesia, duration of postoperative ventilation, perioperative complications, condition at discharge, and duration of intensive care unit & hospital stay were recorded. There was no significant difference in intensive care unit or hospital stay between the groups. However, a significant difference in intraoperative heart rate and mean arterial pressure was observed. The incidence of intraoperative tachycardia and hypotension was significantly higher in the N2O free group. Other intra- and post-operative parameters, perioperative complications, and conditions at discharge were comparable. Use of N2O anesthesia for cerebellopontine tumor surgery in good physical grade and well-optimized patients neither increases the length of intensive care unit or hospital stay nor does it affect the complications and conditions at discharge. However, future studies in poor-grade patients with large tumors and raised intracranial pressure will be required to draw a definitive conclusion.
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Affiliation(s)
- Barkha Bindu
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Gyaninder Pal Singh
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Mihir Prakash Pandia
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Ott S, Lübke A, Mohme M, Westphal M. A 64-year progression of an intradiploic epidermoid of the frontal skull: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23614. [PMID: 38109733 PMCID: PMC10732322 DOI: 10.3171/case23614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/16/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Epidermoid cyst tumors can arise as intradiploic tumors in the frontal skull bones around the fontanel in childhood but are mostly found at the frontal or frontotemporal base of the brain or in the cerebellopontine angle. Therefore, finding a symptomatic intradiploic lesion in the convexity in late adulthood is uncommon. Intradiploic epidermoids can cause complications as they grow, by eroding and perforating their surroundings, and in cases of destruction of the wall of a pneumatized sinus, they can cause pneumocephalus. OBSERVATIONS In the present case, a female patient presented with a skull lesion that had grown progressively over 64 years, resulting in spontaneous pneumocephalus. Surgery with subsequent cranioplasty was performed. The histological examination confirmed the presence of an intradiploic epidermoid. LESSONS This case highlights that complete resection of the lesion with subsequent cranioplasty is recommended before symptoms and reconstructive challenges due to the enormous size of the defect. This case serves as a reminder that intradiploic epidermoids, although uncommon, will expand throughout life and can cause significant complications such as pneumocephalus after decades. Timely surgical interventions after diagnosis are recommended to prevent further complications and to achieve a successful outcome in terms of complete resection and reconstruction.
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Affiliation(s)
- Stefanie Ott
- Department of Neurosurgery, UKE Hamburg Eppendorf, Hamburg, Germany; and
| | - Andreas Lübke
- Center for Diagnostics, Institute of Pathology with the Sections Molecular Pathology and Cytopathology, UKE Hamburg Eppendorf, Hamburg, Germany
| | - Malte Mohme
- Department of Neurosurgery, UKE Hamburg Eppendorf, Hamburg, Germany; and
| | - Manfred Westphal
- Department of Neurosurgery, UKE Hamburg Eppendorf, Hamburg, Germany; and
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Yuan T, Chen Y, Zhu G, Zhang J. The Related Factors and Effect of Electrode Displacement on Motor Outcome of Subthalamic Nuclei Deep Brain Stimulation in Parkinson's Disease. J Clin Med 2023; 12:7561. [PMID: 38137630 PMCID: PMC10744115 DOI: 10.3390/jcm12247561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/11/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Previous studies have revealed the existence of electrode displacement during subthalamic nucleus deep brain stimulation (STN-DBS). However, the effect of electrode displacement on treatment outcomes is still unclear. In this study, we aimed to analyze the related factors of electrode displacement and assess postoperative electrode displacement in relation to the motor outcomes of STN-DBS. METHODS A total of 88 patients aged 62.73 ± 6.35 years (55 males and 33 females) with Parkinson's disease undergoing STN-DBS, with comprehensive clinical characterization before and 1 month after surgery, were involved retrospectively and divided into a cross-incision group and cannula puncture group according to different dura opening methods. The electrode displacement, unilateral pneumocephalus volume percent (uPVP), and brain volume percent were estimated. RESULTS A significant anterior and lateral electrode displacement was observed among all implanted electrodes after pneumocephalus absorption (p < 0.0001). The degree of electrode displacement was positively correlated with the uPVP (p = 0.005) and smaller in females than males (p = 0.0384). Electrode displacement was negatively correlated with motor improvement following STN-DBS in both on-medication and off-medication conditions (p < 0.05). Dural puncture reduced the uPVP (p < 0.0001) and postoperative electrode displacement (p = 0.0086) compared with dural incision. CONCLUSIONS Electrode displacement had a negative impact on the therapeutic efficacy of STN-DBS. Opening the dura via cannula puncture is recommended to increase the accuracy of the lead implantation.
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Affiliation(s)
- Tianshuo Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yingchuan Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Guanyu Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Neurostimulation, Beijing 100070, China
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Wu B, Xu J, Zhang C, Ling Y, Yang C, Xuan R, Wang S, Guo Q, Zeng Z, Jiang N, Chen L, Liu J. The Effect of Surgical Positioning on Pneumocephalus in Subthalamic Nucleus Deep Brain Stimulation Surgery for Parkinson Disease. Neuromodulation 2023; 26:1714-1723. [PMID: 36272897 DOI: 10.1016/j.neurom.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/24/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES This research analyzed the effect of surgical positioning on postoperative pneumocephalus and assessed additional potential risk factors of pneumocephalus in subthalamic nucleus (STN) deep brain stimulation (DBS) for Parkinson disease (PD). MATERIALS AND METHODS In this study, 255 consecutive patients with PD who received bilateral STN DBS under general anesthesia were retrospectively included. Of these, 180 patients underwent surgery with their heads in an elevated position, and 75 patients underwent surgery in a supine position. The postoperative pneumocephalus volume was compared between the two groups. Other potential risk factors for pneumocephalus also were analyzed. RESULTS The mean pneumocephalus volume for the group with elevated-head positioning (16.76 ± 15.23 cm3) was greater than for the supine group (3.25 ± 8.78 cm3) (p < 0.001). Multivariable analysis indicated that the pneumocephalus volume was related to surgical positioning, lateral trajectory angle, intraoperative mean arterial pressure (MAP), microelectrode recording (MER) passage number, brain atrophy degree, and the anterior trajectory angle. No correlation was found between pneumocephalus and age, sex, duration of PD, surgery length, or intracranial volume. In the subgroup analysis, the pneumocephalus volume exhibited a negative correlation with intraoperative MAP (r = -0.210, p = 0.005) and positive correlations with degree of brain atrophy (r = 0.242, p = 0.001) and MER passage number (r = 0.184, p = 0.014) in the elevated-head group. Specifically, an MER passage number > 3 was a significant risk factor for pneumocephalus in the elevated-head group. A positive correlation was observed between the pneumocephalus volume and the lateral trajectory angle in both groups (elevated-head positioning, r = 0.153, p = 0.041; supine positioning, r = 0.546, p < 0.001). CONCLUSIONS In patients with PD who were anesthetized and receiving STN DBS, supine positioning reduced pneumocephalus volume compared with patients with PD receiving STN DBS with their heads elevated. The pneumocephalus volume was negatively correlated with intraoperative MAP and positively correlated with the degree of brain atrophy, the lateral trajectory angle, and the MER passage number.
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Affiliation(s)
- Bin Wu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China; Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jiakun Xu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Changming Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yuting Ling
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Chao Yang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ruoheng Xuan
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Simin Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qianqian Guo
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zixia Zeng
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Nan Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ling Chen
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jinlong Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.
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Rathi DK, Kochar SS, Samal S, Saklecha A. Early Mobilization and Rehabilitation to Enhance the Functional Performance of a Hemiparesis Patient Following a Subdural and Subarachnoid Hematoma With Pneumocephalus: A Case Report. Cureus 2023; 15:e51199. [PMID: 38288164 PMCID: PMC10823199 DOI: 10.7759/cureus.51199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/27/2023] [Indexed: 01/31/2024] Open
Abstract
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.
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Affiliation(s)
- Disha K Rathi
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shraddha S Kochar
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Snehal Samal
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Akshaya Saklecha
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Naganawa S, Ito R, Kawamura M, Taoka T. Intracranial Air Absorption through Arachnoid Granulation: New Considerations from Transsphenoidal Surgery and Implications for Neurofluid Dynamics. Magn Reson Med Sci 2023:bc.2023-0122. [PMID: 37952943 DOI: 10.2463/mrms.bc.2023-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
Postsurgery intracranial air usually diminishes, presumably merging with cerebrospinal fluid (CSF) and venous circulation. Our study presents two transsphenoidal surgery cases, highlighting potential air absorption by arachnoid granulation (AG)-an underexplored phenomenon. AG has long been deemed pivotal for CSF absorption, but recent perspectives suggest a significant role in waste clearance, neuroinflammation, and neuroimmunity. These cases may stimulate renewed research on the multifaceted role of AG in neurofluid dynamics and potentially elucidate further AG functions.
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Affiliation(s)
- Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Rintaro Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Department of Innovative Biomedical Visualization (iBMV), Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Mariko Kawamura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toshiaki Taoka
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Department of Innovative Biomedical Visualization (iBMV), Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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12
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Azab MA, Hazem A, Lucke-Wold B. Tension pneumocephalus as a complication of surgical evacuation of chronic subdural hematoma: case report and literature review. Explor Neuroprotective Ther 2023; 3:177-185. [PMID: 37799771 PMCID: PMC10552714 DOI: 10.37349/ent.2023.00046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/22/2023] [Indexed: 10/07/2023]
Abstract
The management of symptomatic chronic subdural hematoma (CSDH) is surgical evacuation and prognosis in most cases is good. Tension pneumocephalus is the presence of air under pressure in the intracranial cavity. A case of tension pneumocephalus developing as a complication of burr hole evacuation of CSDH is illustrated. In this case, tension pneumocephalus was managed by reopening the wound and saline irrigation with a subdural drain placement. Considering this case report and after a careful review of the literature, the physiopathology, diagnosis, and treatment of this complication are highlighted in the article.
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Affiliation(s)
- Mohammed A. Azab
- Department of Neurosurgery, Cairo University, Cairo 11562, Egypt
| | - Ahmed Hazem
- Department of Neurosurgery, Cairo University, Cairo 11562, Egypt
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610, USA
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13
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Naboulsi WK, Lantz R, Khan A. From Eardrum to Cranium: Pneumocephalus Secondary to Acute Otitis Media. Cureus 2023; 15:e43756. [PMID: 37727174 PMCID: PMC10506660 DOI: 10.7759/cureus.43756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
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.
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Affiliation(s)
- Waseem K Naboulsi
- Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, USA
| | - Rebekah Lantz
- Internal Medicine, Miami Valley Hospital, Dayton, USA
| | - Asif Khan
- Infectious Diseases, Dartmouth Hitchcock Medical Center, Dartmouth, USA
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14
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Wang TY, Tabarestani TQ, Mehta VA, Kranz PG, Gray LL, Brooks K, Brown DA, Fernandez-Moure JS, Schwab J, Than KD. Enterothecal fistula as a rare cause of adult pneumocephalus and meningitis: a case report. J Spine Surg 2023; 9:201-208. [PMID: 37435328 PMCID: PMC10331501 DOI: 10.21037/jss-22-89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 03/14/2023] [Indexed: 07/13/2023]
Abstract
Background Enterothecal fistulas are pathological connections between the gastrointestinal system and subarachnoid space. These rare fistulas occur mostly in pediatric patients with sacral developmental anomalies. They have yet to be characterized in an adult born without congenital developmental anomaly yet must remain on the differential diagnosis when all other causes of meningitis and pneumocephalus have been ruled out. Good outcomes rely on aggressive multidisciplinary medical and surgical care, which are reviewed in this manuscript. Case Description A 25-year-old female with history of a sacral giant cell tumor resected via anterior transperitoneal approach followed by posterior L4-pelvis fusion presented with headaches and altered mental status. Imaging revealed that a portion of small bowel had migrated into her resection cavity and created an enterothecal fistula resulting in fecalith within the subarachnoid space and florid meningitis. The patient underwent a small bowel resection for fistula obliteration, and subsequently developed hydrocephalus requiring shunt placement and two suboccipital craniectomies for foramen magnum crowding. Ultimately, her wounds became infected requiring washouts and instrumentation removal. Despite a prolonged hospital course, she made significant recovery and at 10-month following presentation, she is awake, oriented, and able to participate in activities of daily living. Conclusions This is the first case of meningitis secondary to enterothecal fistula in a patient without a previous congenital sacral anomaly. Operative intervention for fistula obliteration is the primary treatment and should be performed at a tertiary hospital with multidisciplinary capabilities. If recognized quickly and appropriately treated, there is a possibility of good neurological outcome.
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Affiliation(s)
- Timothy Y. Wang
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Vikram A. Mehta
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter G. Kranz
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Linda L. Gray
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Kelli Brooks
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - David A. Brown
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Joseph Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Khoi D. Than
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
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15
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Riga M, Koursoumi E, Kostopanagiotou GG, Matsota P. Unusual Presentation of Pneumocephalus With Late Onset During Labour Epidural Analgesia. Cureus 2023; 15:e39888. [PMID: 37404401 PMCID: PMC10315179 DOI: 10.7759/cureus.39888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/06/2023] Open
Abstract
A 36-year-old woman with no significant medical history was in active labour and requested labour analgesia. While the epidural technique was performed at the L4-L5 interspace, using the loss of resistance to air technique (LORA), inadvertent dural puncture occurred. Since the patient reported no headache or discomfort, the same procedure was repeated at the L3-L4 interspace successfully. Loss of resistance was reported at 3 cm and the epidural catheter was advanced uneventfully at 8 cm. Aspiration was negative for blood or cerebrospinal fluid (CSF) and a test dose of 2 ml lidocaine 2% was administered epidurally. Within five minutes the patient exhibited a mild hypotensive episode successfully treated with 2.5 mg ephedrine IV, a sensory blockade up to T6 level, and a motor blockade up to T10 level. Both the woman's and the baby's vital signs remained stable, no further drugs were administered epidurally and labour progressed painlessly and uncomplicated for 90 minutes with subsequent vaginal delivery of a healthy newborn. During the episiotomy incision repair, the patient complained of light dizziness and nausea. Her vital signs and the arterial blood gases (ABGs) ordered were within normal range, but the neurological examination revealed an isolated Babinski on the right foot. The head CT scan requested indicated a considerable quantity of air within the subarachnoid region. The patient was treated conservatively; symptoms showed steady improvement with total resolution on the sixth day, and the woman was discharged. This case reemphasizes the possibility of pneumocephalus, which may, in reality, occur more frequently than is commonly recognized without a CT confirmation.
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Affiliation(s)
- Maria Riga
- 2nd Department of Anesthesiology, Attikon University Hospital, Athens, GRC
- School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
| | - Evgenia Koursoumi
- 2nd Department of Anesthesiology, Attikon University Hospital, Athens, GRC
| | | | - Paraskevi Matsota
- 2nd Department of Anesthesiology, Attikon University Hospital, Athens, GRC
- School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
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16
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Oomrigar SC, Patel RK, Mas RP, Fernandez JC, Zapata DI. Pneumocephalus With Stroke-Like Symptoms: A Rare Complication of Mastoiditis. Cureus 2023; 15:e40307. [PMID: 37448401 PMCID: PMC10337702 DOI: 10.7759/cureus.40307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Pneumocephalus is defined as the presence of gas or air in the intracranial space and typically arises as a result of neurotrauma. Clinically, pneumocephalus most often presents asymptomatically but may cause headache, nausea, vomiting, and confusion. Pneumocephalus arising from mastoiditis is an unforeseen complication with only a handful of cases reported. We report a case of an elderly male who presented with stroke-like symptoms in the setting of erosive mastoiditis with pneumocephalus.
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Affiliation(s)
| | - Raina K Patel
- Allopathic Medicine, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Robert P Mas
- Internal Medicine, HCA Florida Kendall Hospital, Miami, USA
| | | | - Daniel I Zapata
- Pulmonary and Critical Care Medicine, HCA Florida Kendall Hospital, Miami, USA
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17
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Fetz A, Ghaseminejad F, Kim HJ, Gan SI. Code Stroke Postendoscopy: A Case of Pneumocephalus From a Spinal-Esophageal Fistula. ACG Case Rep J 2023; 10:e01057. [PMID: 37305800 PMCID: PMC10249714 DOI: 10.14309/crj.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Esophageal fistula to the respiratory tract and mediastinum is a well-described complication from esophageal malignancies. Spinal-esophageal fistula (SEF) on the other hand is a much rarer complication that has only been reported in few instances. Here, we report a unique case of fatal spinal-esophageal fistula with an associated pneumocephalus in an 83-year-old woman with metastatic esophageal squamous cell carcinoma.
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Affiliation(s)
- Andrew Fetz
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Farhad Ghaseminejad
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hyun Jae Kim
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - S. Ian Gan
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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18
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Sonfack DJN, Tarabay B, Shen J, Wang Z, Boubez G, Shédid D, Yuh SJ. Pneumorrhachis and pneumocephalus resulting from pneumothorax: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE23129. [PMID: 37212417 PMCID: PMC10550525 DOI: 10.3171/case23129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/06/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Pneumorrhachis and pneumocephalus are rare conditions in which air is found within the spinal canal and brain, respectively. It is mostly asymptomatic and can be located in the intradural or extradural space. Intradural pneumorrhachis should prompt clinicians to search and treat any underlying injury of the skull, chest, or spinal column. OBSERVATIONS A 68-year-old man presented with a history of cardiopulmonary arrest together with pneumorrhachis and pneumocephalus following a recurrent pneumothorax. The patient reported acute headaches with no other neurological symptoms. He was managed conservatively with bed rest for 48 hours following thoracoscopic talcage of his pneumothorax. Follow-up imaging showed regression of the pneumorrhachis, and the patient reported no other neurological symptoms. LESSONS Pneumorrhachis is an incidental radiological finding that self-resolves with conservative management. However, it can be a complication resulting from a serious injury. Therefore, close monitoring of neurological symptoms and complete investigations should be performed in patients with pneumorrhachis.
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Affiliation(s)
| | | | - Jesse Shen
- Orthopedics, Centre Hospitalier Universitaire de Montréal, Montreal, Quebec, Canada
| | - Zhi Wang
- Orthopedics, Centre Hospitalier Universitaire de Montréal, Montreal, Quebec, Canada
| | - Ghassan Boubez
- Orthopedics, Centre Hospitalier Universitaire de Montréal, Montreal, Quebec, Canada
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19
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Wankhade BS, Beniamein MMK, Alrais ZF, Mathew JI, Alrais GZ. What should an intensivist know about pneumocephalus and tension pneumocephalus? Acute Crit Care 2023; 38:244-248. [PMID: 35545242 PMCID: PMC10265419 DOI: 10.4266/acc.2021.01102] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/11/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Collection of air in the cranial cavity is called pneumocephalus. Although simple pneumocephalus is a benign condition, accompanying increased intracranial pressure can produce a life-threatening condition comparable to tension pneumothorax, which is termed tension pneumocephalus. We report a case of tension pneumocephalus after drainage of a cerebrospinal fluid hygroma. The tension pneumocephalus was treated with decompression craniotomy, but the patient later died due to the complications related to critical care. Traumatic brain injury and neurosurgical intervention are the most common causes of pneumocephalus. Pneumocephalus and tension pneumocephalus are neurosurgical emergencies, and anesthetics and intensive care management like the use of nitrous oxide during anesthesia and positive pressure ventilation have important implications in their development and progress. Clinically, patients can present with various nonspecific neurological manifestations that are indistinguishable from a those of a primary neurological condition. If the diagnosis is questionable, patients should be investigated using computed tomography of the brain. Immediate neurosurgical consultation with decompression is the treatment of choice.
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Affiliation(s)
| | | | - Zeyad Faoor Alrais
- Department of Surgical Intensive Care Medicine, Rashid Hospital, Dubai, UAE
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20
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Dinis-Ferreira S, Jardim M, Freitas D, Nóbrega JJ. Pneumocephalus Secondary to Cerebral Air Embolism After Acute Bleeding in an Emphysema Bulla. Cureus 2023; 15:e39051. [PMID: 37323349 PMCID: PMC10266870 DOI: 10.7759/cureus.39051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
Pneumocephalus is the presence of air in the intracranial space and has multiple causes, including cerebral air embolism. Its presentation may range from asymptomatic to decrease mental status, coma, and seizures. We present a case of cerebral air embolism secondary to acute bleeding inside an emphysema bulla. A 69-year-old female was brought to the emergency room after suffering acute dyspnea, convulsions, and cardiac arrest during a commercial flight. The Head CT showed the presence of multiple small gas collections in the brain, and the Thoracic Angiotomography showed a thin-walled bulla surrounded with pulmonary venous vascular structures and signs of active bleeding. The patient had rapid neurological deterioration with evolution to brain death due to anoxic encephalopathy before the possibility of treatment with pulmonary lobectomy and hyperbaric oxygen therapy. It is important to identify the localization of pneumocephalus to determine its etiology and to deliver the best treatment. Cerebral air embolism may happen when air enters the arterial or venous system, which can cause brain damage due to capillary leak syndrome and local ischemia. Treatment of pneumocephalus includes treating the cause, bed rest, avoidance of Valsalva maneuvers, positive pressure, and hyperbaric oxygen therapy. Early recognition is essential to prevent complications such as irreversible brain lesions and to improve patient outcomes.
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Affiliation(s)
| | | | | | - José J Nóbrega
- Intensive Care Department, Hospital Central do Funchal, Funchal, PRT
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21
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Castelnuovo P, Valentini M, Sileo G, Battaglia P, Bignami M, Turri-Zanoni M. Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review. Acta Otorhinolaryngol Ital 2023; 43:S14-S27. [PMID: 37698096 PMCID: PMC10159643 DOI: 10.14639/0392-100x-suppl.1-43-2023-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 09/13/2023]
Abstract
Cerebrospinal fluid leak (CSFL) is a rare pathological condition which requires prompt and adequate management due to the high rate of associated major complications. At present, CSFL can be successfully treated through endoscopic endonasal approaches with success rates higher than 90%. Despite this, CSFL recurrence may occur, and its management is critical and still represents a matter of debate. A systematic review of the literature on the management of recurrent CSFL was conducted. It included a cohort of 1,083 cases of CSFL treated with surgical or conservative approaches; 112 cases of recurrence were reported for an overall recurrence rate of 10.3%. Most of the leaks were localised in the anterior skull base (68.3%) and identification of recurrent CSFL may be troublesome. Therefore, the entire skull base must be meticulously examined and long-term follow-up is mandatory. The risk for CSFL recurrence is higher in patients affected by idiopathic intracranial hypertension (IIH), but its role in CSFL recurrence is yet to be understood. Recurrent CSFL must be repaired as soon as possible in order to reduce the risk of intracranial complications. The use of early post-operative CSF diversion by lumbar drain (LD) is currently a matter of debate even in case of CSFL recurrences.
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Affiliation(s)
- Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Marco Valentini
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Giorgio Sileo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Paolo Battaglia
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Maurizio Bignami
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Lariana, Como, Italy
| | - Mario Turri-Zanoni
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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22
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Takigawa T, Morita T, Taoka T, Ishihara T, Ito Y. Pneumocephalus After Anterior Lumbar Spinal Surgery Due to Trauma: A Case Report. Cureus 2023; 15:e37726. [PMID: 37206497 PMCID: PMC10191756 DOI: 10.7759/cureus.37726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/21/2023] Open
Abstract
Pneumocephalus as a complication of anterior lumbar spinal surgery is extremely rare. A 53-year-old male patient presented with L4 fracture. Posterior fixation from L3 to L5 was conducted one day after the trauma. As the patient's neurological deficit persisted, additional anterior surgery by L4 vertebral body replacement was performed on the 19th day. Both surgeries were completed without obvious intraoperative complications. Two weeks after the anterior lumbar surgery, the patient complained of severe headaches, and computed tomography scan revealed pneumocephalus and massive fluid retention in the abdomen. The symptoms improved with conservative treatment, including bed rest, spinal drainage, intravenous drip infusion, and prophylactic administration of antibiotics. Due to the lack of tamponade effect in the soft tissues, a large amount of cerebrospinal fluid leakage may induce and cause progression of pneumocephalus in anterior dural injury.
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Affiliation(s)
- Tomoyuki Takigawa
- Department of Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe, JPN
| | - Takuya Morita
- Department of Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe, JPN
| | - Takuya Taoka
- Department of Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe, JPN
| | - Takeshi Ishihara
- Department of Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe, JPN
| | - Yasuo Ito
- Department of Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe, JPN
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23
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Helmink AJ, Wahlig TA, Fey PD, Chen J, Foster KW. 60-year-old male with rapidly progressive pneumocephalus caused by Clostridium septicum in the setting of an occult colonic adenocarcinoma. BMC Infect Dis 2023; 23:189. [PMID: 36997864 PMCID: PMC10061804 DOI: 10.1186/s12879-023-08160-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/14/2023] [Indexed: 04/01/2023] Open
Abstract
Background Disseminated Clostridium septicum infection is an uncommon complication associated with malignancies, particular colonic adenocarcinoma. The organism appears to preferentially colonize large masses in rare individuals and subsequently seed the blood via mucosal ulceration. This has rarely been reported to lead to central nervous system infection and, in several cases, rapidly progressive pneumocephalus. In the few cases reported, this was a universally fatal condition. The current case adds to the reports of this extremely rare complication and provides a unique and complete clinicopathologic characterization with autopsy examination, microscopy, and molecular testing. Case Presentation A 60-year-old man with no known past medical history was discovered having seizure-like activity and stroke-like symptoms. Blood cultures turned positive after six hours. Imaging revealed a large, irregular cecal mass as well as 1.4 cm collection of air in the left parietal lobe that progressed to over 7 cm within 8 h. By the following morning, the patient had lost all neurologic reflexes and died. Post-mortem examination revealed brain tissue with multiple grossly evident cystic spaces and intraparenchymal hemorrhage, while microscopic exam showed diffuse hypoxic-ischemic injury and gram-positive rods. Clostridium septicum was identified on blood cultures and was confirmed in paraffin embedded tissue from the brain by 16 S ribosomal sequencing and from the colon by C. septicum specific PCR. Conclusions C. septicum is an anaerobic, gram-positive rod that can become invasive and is strongly associated with gastrointestinal pathology including colonic adenocarcinomas. Central nervous system infection with rapidly progressive pneumocephalus is a rarely reported and universally fatal complication of disseminated C. septicum infection.
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Affiliation(s)
- Austin J. Helmink
- grid.266813.80000 0001 0666 4105Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Taylor A. Wahlig
- grid.266813.80000 0001 0666 4105Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Paul D. Fey
- grid.266813.80000 0001 0666 4105Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Jie Chen
- grid.266813.80000 0001 0666 4105Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Kirk W. Foster
- grid.266813.80000 0001 0666 4105Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198 USA
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24
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Malhotra AK, Chang AP, Lawton JP, Alves AC, Jerath A, Tillmann BW, Foster H, Mashari A, da Costa L, Kumar A. Intraoperative air embolism diagnosis and treatment using hyperbaric oxygen therapy after craniotomy: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE2342. [PMID: 36941197 PMCID: PMC10550683 DOI: 10.3171/case2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 02/24/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND This report describes the use of hyperbaric oxygen therapy for the acute management of an intraoperative air embolism encountered during a neurosurgical procedure. Furthermore, the authors highlight the concomitant diagnosis of tension pneumocephalus requiring evacuation prior to hyperbaric therapy. OBSERVATIONS A 68-year-old male developed acute ST-segment elevation and hypotension during elective disconnection of a posterior fossa dural arteriovenous fistula. The semi-sitting position had been used to minimize cerebellar retraction, raising the concern for acute air embolism. Intraoperative transesophageal echocardiography was utilized to establish the diagnosis of air embolism. The patient was stabilized on vasopressor therapy, and immediate postoperative computed tomography revealed air bubbles in the left atrium along with tension pneumocephalus. He underwent urgent evacuation for the tension pneumocephalus followed by hyperbaric oxygen therapy to manage the hemodynamically significant air embolism. The patient was eventually extubated and went on to fully recover; a delayed angiogram revealed complete cure of the dural arteriovenous fistula. LESSONS Hyperbaric oxygen therapy should be considered for an intracardiac air embolism resulting in hemodynamic instability. In the postoperative neurosurgical setting, care should be taken to exclude pneumocephalus requiring operative intervention prior to hyperbaric therapy. A multidisciplinary management approach facilitated expeditious diagnosis and management for the patient.
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Affiliation(s)
- Armaan K. Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ashton P. Chang
- Department of Anesthesiology, Sunnybrook Health Sciences, Toronto, Ontario, Canada
| | - Joseph P. Lawton
- Department of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Aderaldo Costa Alves
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health SciencesCentre, Toronto, Ontario, Canada
| | - Angela Jerath
- Department of Anesthesiology, Sunnybrook Health Sciences, Toronto, Ontario, Canada
- Department of Anesthesiology, Schulich Heart Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bourke W. Tillmann
- Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdeparmtental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; and
| | - Harry Foster
- Department of Anesthesiology, Sunnybrook Health Sciences, Toronto, Ontario, Canada
- Department of Anesthesiology, Schulich Heart Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Azad Mashari
- Division of Anesthesiology, University Health Network, Toronto, Ontario, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health SciencesCentre, Toronto, Ontario, Canada
| | - Ashish Kumar
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health SciencesCentre, Toronto, Ontario, Canada
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25
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Kim HS, Kim JH, Kim DK, Ha SW. Tension Pneumocephalus Caused by Ethmoidal Roof Fracture: Emergent Surgical Decompression. Diagnostics (Basel) 2022; 13. [PMID: 36611383 DOI: 10.3390/diagnostics13010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Tension pneumocephalus is a neurosurgical emergency that occurs when air is trapped in the intracranial cavity, leading to brain compression and causing severe neurological symptoms such as decreases in motor function, sensory function, and consciousness. Most cases of pneumocephalus require conservative treatment; however, because of the possible fatal complications, rapid diagnosis and appropriate treatment are important. Here, we present the case of an 81-year-old male patient who had undergone head trauma three hours prior to being admitted to our emergency room (ER) because of mental cloudiness. The radiologic findings showed tension pneumocephalus caused by an ethmoidal roof fracture. Emergency reconstruction of the ethmoidal roof with craniotomy was performed to remove the intracranial air using normal saline irrigation. By sharing our experience with this case, we hope to provide an option for the treatment of such cases.
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Kang YR, Nam TS, Kim BC, Kim JM, Cho SH, Kang KW, Choi KH, Kim JT, Choi SM, Lee SH, Park MS, Kim MK. Characteristics of patients with meningitis after lumbar epidural steroid injection. Medicine (Baltimore) 2022; 101:e32396. [PMID: 36595762 PMCID: PMC9794205 DOI: 10.1097/md.0000000000032396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
To investigate the clinical, laboratory, and radiological features of meningitis after lumbar epidural steroid injection (M-ESI) without accompanying spinal infection, data of patients with meningitis admitted between January 2014 and December 2021 in a single center were retrospectively reviewed. Among them, patients with a recent history of lumbar ESI were identified, and their medical records were collected. Patients with concomitant infections other than meningitis, including spinal epidural abscess, were excluded. Seven patients with M-ESI were identified. All patients presented with headache and fever without focal neurological deficits, and headache developed shortly after a procedure (median, 4 hours). Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis (median, 6729/μL), elevated protein level (median, 379.1 mg/dL), decreased ratio of CSF glucose to serum glucose (median, 0.29), and elevated lactate level (median, 8.64 mmol/L). Serum level of C-reactive protein was elevated in 6, but serum procalcitonin level was within normal range. No causative pathogen was identified in the microbiological studies. The most frequent radiologic feature was sulcal hyperintensity on fluid-attenuated inversion recovery images (57%), followed by pneumocephalus (43%). Symptoms subsided in a short period (median, 1 day) after initiating treatment with antibiotics and adjuvant intravenous corticosteroids. None of the patients experienced neurological sequelae. Though the cardinal symptoms and CSF findings of M-ESI were comparable to those of bacterial meningitis, M-ESI seems to have distinctive characteristics regarding the clinical course, laboratory parameters, and pneumocephalus.
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Affiliation(s)
- You-Ri Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
- * Correspondence: Tai-Seung Nam, Department of Neurology, Chonnam National University Medical School and Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 61469, South Korea (e-mail: )
| | - Byeong C. Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - Jae-Myung Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Soo Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
- Department of Neurology, Chonnam National University Hwasun Hospital, Jeollanam-do, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - Seong-Min Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - Seung-Han Lee
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
| | - Myeong-Kyu Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea
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Wang HP, Reif RJ, Kalkwarf KJ, Jensen HK, Jenkins AK, Bhavaraju A. Prophylactic Antibiotics in Patients with Traumatic Pneumocephalus or Cerebrospinal Fluid Leak. Am Surg 2022:31348221117041. [PMID: 35979960 DOI: 10.1177/00031348221117041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pneumocephalus and cerebrospinal fluid (CSF) leaks are uncommon after trauma, but they expose the sterile CSF to environmental pathogens and create theoretical risk of central nervous system infection (CNSI). Prophylactic antibiotics are commonly given to these patients, but there is a paucity of evidence to guide this practice. We aim to quantify the incidences of these entities and analyze the efficacy of prophylactic antibiotics in preventing CNSIs. METHODS A retrospective cohort study was conducted using our institutional trauma registry. All patients admitted from January 2014 to July 2020 with traumatic pneumocephalus (TP) or basilar skull fracture with CSF leak (BSF-CSF) were included. ICD-9 and ICD-10 codes were used to identify CNSIs. CNSI rates among defined prophylactic antibiotic regimens, no antibiotics, and other antibiotic regimens were evaluated. ANOVA was used to analyze differences between the groups. RESULTS 365 patients met inclusion criteria: 360 with TP; 5 with BSF-CSF. 1.1% (4/365) of patients developed CNSI, all with isolated traumatic pneumocephalus. 1.4% of patients (1/72) without antibiotics; 1.2% (3/249) receiving IV antibiotics outside of a defined regimen; and 1.1% (1/88) on a designated prophylactic regimen developed CNSIs. ANOVA indicated the incidence of CNSI was not significantly different among patients who received antibiotics or not, regardless of the regimen (p-value 0.958). CONCLUSION TP and BSF-CSF are rare diagnoses among trauma patients. The rate of CNSI is marginal and antibiotics do not appear to confer a protective advantage. A larger trial is needed to elucidate the true effect of antibiotics on preventing CNSIs in patients with these uncommon diagnoses.
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Affiliation(s)
- Hsin-Ping Wang
- Department of Surgery, Division of Trauma and Acute Care Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca J Reif
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, Division of Trauma and Acute Care Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hanna K Jensen
- Department of Surgery, Division of Trauma and Acute Care Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Allison K Jenkins
- Department of Surgery, Division of Trauma and Acute Care Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Avi Bhavaraju
- Department of Surgery, Division of Trauma and Acute Care Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
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28
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Gumeler E, Oguz KK. An Unusual Pattern of Skull Base Pneumatization. Ann Otol Rhinol Laryngol 2022:34894221114728. [PMID: 35904196 DOI: 10.1177/00034894221114728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Our aim is to describe an unusual pattern of craniocervical pneumatization resulting in a spontaneous fracture in a patient, who presented with tinnitus. METHODS Temporal CT was ordered in a patient with tinnitus lasting over a year. His audiogram was normal. No history of previous trauma, recent flight, diving, or weight lifting was present. Further questioning revealed his habitual Valsalva maneuvers to relieve symptoms of nasal congestion. RESULTS Temporal CT showed abnormal pneumatization of the occipital bone and C1 vertebra. A definite cortical defect resulted with the presence of air around the neighboring soft tissues. The emphysema was most prominent in the suboccipital fossa but it was also seen in the epidural space of the spinal canal. CONCLUSION Abnormal pneumatization of the skull base and cervical vertebra can be symptomatic due to its tendency to fracture. The presumed cause of pneumatization in this patient is habitual Valsalva maneuvers.
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Affiliation(s)
- Ekim Gumeler
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kader K Oguz
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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29
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Yang CT, Chiu CD, Wu CY. Diffuse symptomatic pneumocephalus after biportal endoscopic spinal surgery: illustrative case. J Neurosurg Case Lessons 2022; 3:CASE22168. [PMID: 35855204 PMCID: PMC9237657 DOI: 10.3171/case22168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Percutaneous endoscopic lumbar decompression is gaining attention as a minimally invasive surgery. Here, the authors report a rare complication of pneumocephalus caused by vacuum drain after biportal endoscopic spinal surgery (BESS) for lumbar stenosis. OBSERVATIONS A 79-year-old woman with spinal stenosis over the L4-5 level received BESS. No visible dural tear was encountered during surgery, and a vacuum drain was placed after surgery. Approximately 150 mL of cerebrospinal fluid was drained on postoperative day 1. Simultaneously, symptoms of intracranial hypotension were noted. Brain computed tomography (CT) revealed pneumocephalus. The patient was advised to have bed rest and hydration, and her symptoms improved subsequently. Follow-up brain CT indicated the resolution of pneumocephalus. LESSONS Pneumocephalus after endoscopic lumbar surgery is rare. Dural tear, high rate of normal saline irrigation, and vacuum drain placement are the associated risk factors.
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Affiliation(s)
- Chien-Tung Yang
- School of Medicine, Kaoshiung Medical University, Kaoshiung, Taiwan.,Neurosurgical Department, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Di Chiu
- Graduate Institute of Biomedical Science, China Medical University, Taichung, Taiwan.,Neurosurgical Department, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Ying Wu
- Neurosurgical Department, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; and.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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30
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Bruckmann C, Bruckmann L, Gahleitner A, Stavropoulos A, Bertl K. Pneumocephalus as result of nonsurgical peri-implantitis treatment with an air-polishing device for submucosal debridement-A case report. Clin Exp Dent Res 2022; 8:632-639. [PMID: 35502527 PMCID: PMC9209792 DOI: 10.1002/cre2.578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background A subcutaneous emphysema is an infrequent but potentially life‐threatening complication after dental treatment involving instruments functioning with pressurized air. Emphysemata after the use of high‐speed handpieces and air‐syringes are well documented, however, more recently several reports on emphysemata produced by air‐polishing devices during management of peri‐implant biological complications have appeared. To the best of our knowledge, direct development of pneumocephalus after a dental procedure has never been reported before. Introduction of air likely contaminated with oral bacteria to the intracranial space bares the risk of developing meningitis. Case Presentation This case report describes the spreading of a subcutaneous emphysema into the intracranial space (i.e., development of a pneumocephalus) after treatment of a peri‐implantitis lesion with an air‐polishing device equipped with the nozzle for submucosal debridement. A subcutaneous emphysema was noticed during the use of an air‐polishing device and the subsequent computed tomography (CT) examination revealed a quite unexpected spreading of the emphysema into the intracranial space. The patient was admitted to the hospital for close surveillance, CT follow‐up, and intravenous antibiotics to prevent the development of meningitis due to the introduction of air—likely contaminated with oral bacteria—into the intracranial space. After 3 days, the patient was discharged in good condition without any further complications. Conclusion In case of an extensive subcutaneous emphysema as result of a dental procedure, a more extended radiographic examination including the mediastinal and cranial space should be considered, to assess the risk for potentially life‐threatening complications.
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Affiliation(s)
- Corinna Bruckmann
- Division of Conservative Dentistry and Periodontology, University Clinic of Dentistry, Medical University of Vienna, Austria
| | - Lukas Bruckmann
- Neurosurgical Department, Klinik Landstrasse, Vienna, Austria
| | - André Gahleitner
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Andreas Stavropoulos
- Division of Conservative Dentistry and Periodontology, University Clinic of Dentistry, Medical University of Vienna, Austria.,Department of Periodontology, Faculty of Odontology, University of Malmö, Malmö, Sweden
| | - Kristina Bertl
- Division of Oral Surgery, University Clinic of Dentistry, Medical University of Vienna, Vienna, Austria
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31
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Di Dier K, Lemmerling M. Pneumococcal Meningitis. J Belg Soc Radiol 2022; 106:136. [PMID: 36618029 DOI: 10.5334/jbsr.2993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022] Open
Abstract
Teaching Point: Spontaneous, atraumatic pneumocephalus is a rare presentation of pneumococcal meningitis.
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32
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Bhandari S, Baral MR, Yu M. Iatrogenic Pneumocephalus Resolved by Oxygen Therapy. Cureus 2021; 13:e19830. [PMID: 34963846 PMCID: PMC8702392 DOI: 10.7759/cureus.19830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 11/11/2022] Open
Abstract
Iatrogenic pneumocephalus and dural puncture are some causes of headache following cervical epidural injection. A 50-year-old woman presented with a sharp headache at the base of her skull following a cervical epidural injection for chronic neck pain. It was not relieved by lying down and was associated with nausea, vomiting, and photophobia without fever or neck rigidity. Neurological examination failed to show any abnormalities. A head CT scan showed newly evident pneumocephalus in the ventricular system and the extra-axial subarachnoid space within the sulci of the right frontal lobe. Oxygen supplementation was started with the help of a non-rebreather mask connected to 15 liters of oxygen and was slowly down titrated to room air. Repeat CT scan of the head after 48 hours showed complete resolution of the intracranial pneumocephalus. Normobaric oxygen therapy via a non-rebreather mask and a high-flow nasal cannula is effective for the treatment of intracranial pneumocephalus.
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Affiliation(s)
| | - Maun R Baral
- Internal Medicine, Danbury Hospital, Nuvance Health, Danbury, USA
| | - Mingwei Yu
- Internal Medicine, Danbury Hospital, Nuvance Health, Danbury, USA
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33
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Maegawa K, Nishioka H. Pneumocephalus and pneumorrhachis caused by Clostridium perfringens infection. Int J Infect Dis 2021; 115:166-167. [PMID: 34883236 DOI: 10.1016/j.ijid.2021.12.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Kazuki Maegawa
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo 650-0047, Japan
| | - Hiroaki Nishioka
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo 650-0047, Japan.
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34
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da Silva AJF, Malta Doria AL. Intraventricular Pneumocephalus as a Complication of Ventriculoperitoneal Shunt. Cureus 2021; 13:e18392. [PMID: 34725626 PMCID: PMC8555920 DOI: 10.7759/cureus.18392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 11/25/2022] Open
Abstract
Pneumocephalus is defined as the presence of air in the intracranial cavity, and this complication is rare after ventriculoperitoneal shunt (VPS) surgery. It can be caused by traumatic brain injury (TBI), surgical interventions, and anatomical or spontaneous malformation. We present a case of intraventricular pneumocephalus associated with the placement of a VPS. The patient was a 40-year-old man who had a VPS inserted 10-years ago due to hydrocephalus caused by TBI. He presented to the emergency room with complaints of headache, vomiting, rhinoliquorrhea, and fever. Computed tomography of the skull showed ventricular dilatation with intraventricular pneumocephalus. In a three-dimensional reconstruction, a bone defect was visualized with meningocele at the base of the skull that would explain the cerebrospinal fluid fistula. The meningocele was surgically corrected. After 14 days of antibiotic treatment, a new VPS was placed and the patient progressed satisfactorily. Pneumocephalus associated with VPS is a rare condition that can develop secondary to a combination of the shunt effect and an anatomical defect at the base of the skull. Excessively negative and persistent intracranial pressure of the shunt allows air to enter and fill the existing vacuum through the defect in the skull base. This bone defect may be congenital, due to traumatic brain injury, or a result of hydrocephalus itself. Computed tomography of the skull is an excellent investigation for the visualization of bone defects, and treatment involves a correction of the fistula. Pneumocephalus associated with VPS is rare. The presence of rhinoliquorrhea is a strong indication of the condition. Once the presence of a fistula is confirmed, it should be corrected to prevent worsening of the pneumocephalus.
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Affiliation(s)
- Aldo J F da Silva
- Pediatric Neurosurgery Division, Santa Mônica Teaching Maternity-Alagoas State University of Health Sciences, Maceió, BRA
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35
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Marino F, Simões AF, Simas Â, Pereira JG. Pneumocephalus Following an Accidental Dural Puncture, Treated Using Hyperbaric Oxygen Therapy. A Case Report. J Crit Care Med (Targu Mures) 2021; 7:237-40. [PMID: 34722927 DOI: 10.2478/jccm-2021-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/25/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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36
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Rathnayake D, M M B, E T, M U, K T S, Jayasekara PI, Sigera LSM, Welagedara PGRIS, Francis V. A rare case of Escherichia coli and Rhizopus sinusitis complicated with pneumocephalus, E. coli psoas abscess and sepsis. Access Microbiol 2021; 3:000243. [PMID: 34595394 PMCID: PMC8479965 DOI: 10.1099/acmi.0.000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 05/27/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
| | - Basith M M
- Professorial Medical Unit, Teaching hospital, Batticaloa, Sri Lanka
| | - Tharmini E
- Professorial Medical Unit, Teaching hospital, Batticaloa, Sri Lanka
| | - Umakanth M
- Faculty of Medical Sciences, Eastern University of Sri Lanka, Chenkalady, Sri Lanka
| | - Sundaresan K T
- Faculty of Medical Sciences, Eastern University of Sri Lanka, Chenkalady, Sri Lanka
| | | | | | | | - Vaithehi Francis
- Faculty of Medical Sciences, Eastern University of Sri Lanka, Chenkalady, Sri Lanka
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37
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Davies J, Himstead AS, Kim JH, Chan AY, Tran DK, Hsu FP, Vadera S. Use of Automated Irrigating Drainage System in Six Patients With Chronic Subdural Hematoma: A Single-Center Experience. Cureus 2021; 13:e17355. [PMID: 34567895 PMCID: PMC8454598 DOI: 10.7759/cureus.17355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 11/08/2022] Open
Abstract
Background Chronic subdural hematoma (cSDH) is predicted to become the most common intracranial neurosurgical condition by 2030. Recurrence is estimated between 5-15%, and the use of a surgical drain is associated with lower recurrence rates. The authors present their experience with six patients undergoing cSDH evacuation with an irrigating drainage system, comprising the largest single-institution group in the United States (US). Methods IRB-approved, retrospective chart review was performed for six patients who underwent irrigating surgical drain placement during cSDH evacuation. Outcome measures included device settings and duration of the irrigating drain, postoperative length of stay, neurological status at follow-up, and hematoma recurrence. Results There were no recurrences noted within this group at last follow-up, with an average follow-up length over three months. The average postoperative length of stay was 2.67 ± 0.51 days. Patients were drained on average for 1.41 ± 0.49 days at 0cm water, irrigating at 55.25 ± 46.44cc/hr. On postoperative day one, average hematoma size and midline shift (MLS) reduction were respectively 13.43 ± 3.31mm and 5.71 ± 1.33mm. No device-related complications were noted. Conclusion The authors' early experience with this irrigating drainage device demonstrates that it is safe and effective for this population. Although this is a preliminary study on a small sample size, the excellent results warrant further investigation and establishment of a standard protocol to compare against current treatment regimens.
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Affiliation(s)
- Jordan Davies
- Department of Neurological Surgery, University of California Irvine, Irvine, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California Irvine, Irvine, USA
| | - Ji Hyun Kim
- Department of Neuroscience, Johns Hopkins University, Baltimore, USA
| | - Alvin Y Chan
- Department of Neurological Surgery, University of California Irvine, Irvine, USA
| | - Diem Kieu Tran
- Department of Neurological Surgery, University of California Irvine, Irvine, USA
| | - Frank P Hsu
- Department of Neurological Surgery, University of California Irvine, Irvine, USA
| | - Sumeet Vadera
- Department of Neurological Surgery, University of California Irvine, Irvine, USA
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38
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Priestley KL, Bridwell RE, Beach JC, Simon EM, Britton GW. Traumatic Pneumocephalus Without Skull Fracture From a High-Voltage Electrical Injury. Cureus 2021; 13:e16700. [PMID: 34462706 PMCID: PMC8389854 DOI: 10.7759/cureus.16700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Katie L Priestley
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Rachel E Bridwell
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - John C Beach
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA
| | - Erica M Simon
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Garrett W Britton
- Critical Care, United States Army Institute of Surgical Research, Fort Sam Houston, USA
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39
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McCormick JP, Raskin J, Lee JT. Tension Pneumocephalus Following Balloon Sinuplasty. Ear Nose Throat J 2021; 100:859S-861S. [PMID: 34392735 DOI: 10.1177/01455613211037629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Balloon sinus dilation (BSD) is a common method of relieving sinus outflow obstruction. With the rising utilization of BSD, increasing numbers of BSD-related complications have also been reported. Here, we report a case of pneumocephalus and cerebrospinal fluid leak following BSD of the frontal sinus. Additionally, a review of the literature regarding BSD complications was performed.
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Affiliation(s)
- Justin P McCormick
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Jonathan Raskin
- Oakland University William Beaumont School of Medicine, Detroit MI, USA.,Cedars Sinai Sinus Center of Excellence, Los Angeles, CA, USA
| | - Jivianne T Lee
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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Stroie OM, Keinath KV, Knaus CM. Rare Case of Tension Pneumocephalus in Thoracic Trauma. Cureus 2021; 13:e16136. [PMID: 34367762 PMCID: PMC8330511 DOI: 10.7759/cureus.16136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/10/2022] Open
Abstract
Tension pneumocephalus is the presence of air within the cranial vault compressing the ventricles and the brain parenchyma. High altitudes can exacerbate this problem, especially when a dural defect exists and air is forced into the cranial cavity with no way to escape. This case demonstrates a rare presentation of thoracic trauma causing tension pneumocephalus due to emergent air evacuation.
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Affiliation(s)
- Oana M Stroie
- Diagnostic Radiology, Uniformed Services University of the Health Sciences, Bethesda, USA
| | - Kyle V Keinath
- Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, USA
| | - Christopher M Knaus
- Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, USA
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Fujimoto A, Hatano K, Nozaki T, Sato K, Enoki H, Okanishi T. Postoperative Pneumocephalus on Computed Tomography Might Predict Post-Corpus Callosotomy Chemical Meningitis. Brain Sci 2021; 11:638. [PMID: 34063350 DOI: 10.3390/brainsci11050638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A corpus callosotomy (CC) is a procedure in which the corpus callosum, the largest collection of commissural fibers in the brain, is disconnected to treat epileptic seizures. The occurrence of chemical meningitis has been reported in association with this procedure. We hypothesized that intraventricular pneumocephalus after CC surgery represents a risk factor for postoperative chemical meningitis. The purpose of this study was to analyze the potential risk factors for postoperative chemical meningitis in patients with medically intractable epilepsy who underwent a CC. METHODS Among the patients who underwent an anterior/total CC for medically intractable epilepsy between January 2009 and March 2021, participants were comprised of those who underwent a computed tomography scan on postoperative day 0. We statistically compared the groups with (c-Group) or without chemical meningitis (nc-Group) to determine the risk factors. RESULTS Of the 80 patients who underwent a CC, 65 patients (25 females and 40 males) met the inclusion criteria. Their age at the time of their CC procedure was 0-57 years. The c-Group (17%) was comprised of seven females and four males (age at the time of their CC procedure, 1-43 years), and the nc-Group (83%) was comprised of 18 females and 36 males (age at the time of their CC procedure, 0-57 years). Mann-Whitney U-tests (p = 0.002) and univariate logistic regression analysis (p = 0.001) showed a significant difference in pneumocephalus between the groups. CONCLUSION Postoperative pneumocephalus identified on a computed tomography scan is a risk factor for post-CC chemical meningitis.
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Ozaki D, Akashi T, Morita T, Nishimura S, Kanamori M, Tominaga T. A Rare Case of Intracerebral Pneumocephalus Caused by Preexisting Multiple Bone Defects and Encephalocele after Resection of Meningioma. NMC Case Rep J 2021; 8:39-44. [PMID: 34012747 PMCID: PMC8116923 DOI: 10.2176/nmccrj.cr.2020-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/01/2020] [Indexed: 11/20/2022] Open
Abstract
Pneumocephalus is generally secondary to direct damage to the skull base. Spontaneous intracerebral pneumatocele without head injury was extremely rare, but previously reported as a serious complication of shunt procedures. We describe a 40-year-old man with intracerebral pneumocephalus who previously underwent craniotomy for large frontal convexity meningioma and lumbo-peritoneal shunting. He presented with gait disturbance 14 months after tumor resection. Computed tomography and magnetic resonance imaging showed intracerebral pneumocephalus in the right temporal lobe, which continued into the mastoid air cells through a bone defect of the right petrous bone. We performed urgent right temporal craniotomy to reduce the mass effect and to repair the fistula. Intraoperatively, bone defects were identified at the roof petrous bone, into which the encephalocele had penetrated. The herniated cerebral parenchyma was removed, and the pneumocephalus opened. The dura was closed with sutures and covered with fascia. To elucidate the underlying mechanism for the development of intracranial pneumocephalus, the previous images obtained before or immediately after resection of meningioma were reviewed. We founded that multiple preexisting bone defects and encephaloceles, one of which was considered to be the cause of the intracerebral pneumocephalus. This case demonstrates that intracerebral pneumocephalus can be caused by preexisting bone defect and encephalocele, and this finding may be useful for prediction of pneumocephalus after shunt procedures.
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Affiliation(s)
- Dan Ozaki
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Toshiaki Akashi
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Takahiro Morita
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | | | - Masayuki Kanamori
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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43
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Śmiłowska K, Sznajder-Stacha K, Kocyłowski D, Popek A, Rozpondek K, Grechuta M, Salari M. Pneumocephalus as a rare complication: a systematic review plus clinical vignette. Neurol Neurochir Pol 2021; 55:253-268. [PMID: 33543469 DOI: 10.5603/pjnns.a2021.0014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/09/2020] [Accepted: 12/31/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pneumocephalus is a clinical entity characterised by the presence of gas in the intracranial space. It can result from many different causes. The most common cause is head or facial trauma. Other causes include neoplasms, infections, and surgical or diagnostic procedures. Spontaneous non-traumatic pneumocephalus is a rare condition caused by bone defects, malformations, infections, tumours, intravenous air injection, and other causes. This review, supplemented with a case presentation, aims to summarise the current state of knowledge regarding non-traumatic pneumocephalus. METHODOLOGY This review involved an electronic search (PubMed, Scopus, Embase, and Web of Science) to identify studies regarding non-traumatic pneumocephalus. In addition, reference lists of identified articles were screened for other potentially relevant papers. RESULTS In total, 1,107 articles were retrieved by searching databases with the selected query. Based on the selection process, 134 articles were included. These articles were then classified into 'otogenic', 'bone defect', 'malformations', 'infectious', 'tumours', 'associated with intravenous air injection', and other categories. CONCLUSION Spontaneous non-traumatic pneumocephalus is a rare condition. Symptoms, clinical courses, and prognoses vary depending on the underlying cause of the disease. To the best of our knowledge, this review's example is the first case report of spontaneous pneumocephalus due to air embolism secondary to lung cancer.
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Affiliation(s)
- Katarzyna Śmiłowska
- Department of Neurology, Regional Specialist Hospital im. Św. Barbary, Sonowiec, Poland.
| | | | - Daniel Kocyłowski
- Department of Neurosurgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Aleksandra Popek
- Department of Radiology, City Hospital in Sosnowiec, Sosnowiec, Poland
| | - Kamila Rozpondek
- Department of Neurology, City Hospital in Sosnowiec, Sosnowiec, Poland
| | - Maciej Grechuta
- Department of Neurology, City Hospital in Sosnowiec, Sosnowiec, Poland
| | - Mehri Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran., Iran, Islamic Republic Of
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Khan MZ, Jamil A, Tahir D, Sidiq R. Tension Pneumocephalus From an Eroding Cholesteatoma: A Case Report and Review of the Literature. Cureus 2021; 13:e12873. [PMID: 33633902 PMCID: PMC7898552 DOI: 10.7759/cureus.12873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Muhammad Z Khan
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Abdur Jamil
- Internal Medicine, Central Michigan University, Saginaw, USA
| | - Danial Tahir
- General Medicine/Pediatrics, Ayub Medical College, Abbottabad, PAK
| | - Ramsha Sidiq
- Internal Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
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Gâta A, Toader C, Trombitaș VE, Ilyes A, Albu S. Endoscopic Skull Base Repair Strategy for CSF Leaks Associated with Pneumocephalus. J Clin Med 2020; 10:E46. [PMID: 33375669 DOI: 10.3390/jcm10010046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/08/2020] [Accepted: 12/23/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Cerebrospinal (CSF) fluid leaks with associated pneumocephalus (PNC) represent a condition bearing serious risks for the patient, with little data available in the literature. Reported success rates of endoscopic skull base repair are lower when PNC is associated than in the case of simple CSF leaks. The present study represents an analysis of our experience with endoscopic management of this condition. Methods: Records of patients with pneumocephalus and associated CSF leaks, who underwent endoscopic skull base repair, were reviewed. Demographics, history, etiology of PNC, size of defect, surgical approach, reconstruction technique and complications were evaluated. Results: Twenty patients with CSF leaks and PNC underwent endonasal repair by the senior author between 2005 and 2019. Defect size was larger than 15 mm in all cases. All patients presented either worsening of PNC under conservative treatment or tension PNC. First-attempt closure of the defect was successful in all patients (100%), with resolution of the pneumocephalus. One patient developed a synechia in the proximity of the frontal ostium, as a postoperative complication. The mean follow-up was 39 months (range: 15–94 months). Conclusion: The present study represents a proposed argument for earlier endoscopic endonasal treatment in patients presenting CSF leaks and pneumocephalus.
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Affiliation(s)
- Aman Deep
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew N Wilner
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Ghahvehchian H, Sadrhosseini SM, Fard MA. Pneumocephalus after Orbital Decompression Surgery for Thyroid Eye Disease. Middle East Afr J Ophthalmol 2020; 27:142-144. [PMID: 32874051 PMCID: PMC7442077 DOI: 10.4103/meajo.meajo_170_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 04/19/2020] [Accepted: 06/06/2020] [Indexed: 11/04/2022] Open
Abstract
A cerebrospinal fluid (CSF) leak is a rare complication after orbital surgery. We reported a 49-year-old man who presented with CSF leakage after transcaruncular medial wall decompression for proptosis due to thyroid eye disease. He underwent an endoscopic endonasal approach to surgical repair of the defect with nasoseptal flap. Rhinorrhea was stopped immediately after endoscopic repair.
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Affiliation(s)
- Hossein Ghahvehchian
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Seyyed M Sadrhosseini
- Department of Otolaryngology, Imam Khomeini Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Masoud A Fard
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Science, Tehran, Iran
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Martino A, Darbin O, Templeton K, Dees D, Lammle M, Torres T, Williams D, Naritoku D. Physical Plasticity of the Brain and Deep Brain Stimulation Lead: Evolution in the First Post-operative Week. Front Surg 2020; 7:55. [PMID: 33062638 PMCID: PMC7477286 DOI: 10.3389/fsurg.2020.00055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/13/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Deep brain stimulation (DBS) is a therapy for movement disorders and psychiatric conditions. In the peri-operative period, brain shift occurs as the consequence of events related to the brain surgery which results in post-operative lead deformation. Objective: To quantify post-operative 3-dimensional DBS lead deformation after implantation. Methods: In 13 patients who had DBS lead implantation, we performed preoperative magnetic resonance imaging (MRI), preoperative computed tomography (CT) scans after placement of fiducial markers, and post-operative CT scans immediately, 24-48 h, and 7 days after implantation. The MRI scans were used to define brain orientation and merged with CT scans. Lead deviation was determined relative to a theoretical linear lead path defined by the skull entry and target lead tip points. Results: In the sagittal plane, we distinguished an initial period after surgery (<48 h) characterized by a deviation of the lead toward the rostral direction and a late period (over 1 week) characterized by a lead deviation toward the caudal direction. In the coronal plane, there was higher probability of lead deviation in the lateral than medial direction. During 7 days after implantation, there was net movement of the center of the lead anteriorly, and the half of the lead close to the entry point moved medially. These deviations appeared normative since all patients included in this study had benefits from DBS therapy with total power of charged comparable to those described in literature. Conclusion: DBS lead deviation occurs during 7 days after implantation. The range of deviation described in this study was not associated to adverse clinical effects and may be considered normative. Future multicenter studies would be helpful to define guide lines on DBS lead deformation and its contribution to clinical outcome.
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Affiliation(s)
- Anthony Martino
- Department of Neurosurgery, College of Medicine, University of South Alabama, Mobile, AL, United States
| | - Olivier Darbin
- Department of Neurology, College of Medicine, University of South Alabama, Mobile, AL, United States
| | - Kelsey Templeton
- Department of Neurosurgery, College of Medicine, University of South Alabama, Mobile, AL, United States
| | - Daniel Dees
- Department of Neurology, College of Medicine, University of South Alabama, Mobile, AL, United States
| | - Markus Lammle
- Department of Neurology, College of Medicine, University of South Alabama, Mobile, AL, United States.,Department of Radiology, Tulane University, New Orleans, LA, United States
| | - Tatiana Torres
- Department of Neurology, College of Medicine, University of South Alabama, Mobile, AL, United States
| | - Dakota Williams
- Department of Neurology, College of Medicine, University of South Alabama, Mobile, AL, United States
| | - Dean Naritoku
- Department of Neurology, College of Medicine, University of South Alabama, Mobile, AL, United States
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Ferrante E, Trimboli M, Cervellino A, Peluso D, Paciello N. Pneumocephalus Associated With Spontaneous Intracranial Hypotension. Headache 2020; 59:1093-1094. [PMID: 31297808 DOI: 10.1111/head.13590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2019] [Indexed: 11/29/2022]
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50
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Pouwels S, Vis L, Ramnarain D, Rutten A. Pneumocephalus and Catatonia in a Patient With Persistent Drain Dysfunctions and Infections After a Hydrocephalus due to an Aquaduct Stenosis: A Case Report. Cureus 2020; 12:e9440. [PMID: 32864264 PMCID: PMC7451076 DOI: 10.7759/cureus.9440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The combination of catatonia and pneumocephalus is very rare and literature is very scarce on this topic. Here, we report a patient with pneumocephalus and catatonia after persistent drain dysfunctions and infections after a hydrocephalus due to an aquaduct stenosis. The combination of a catatonic syndrome and pneumocephalus in neurosurgical and intensive care practice is a rare phenomenon. One should consider it in patients after complicated neurosurgery with pneumocephalus.
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Affiliation(s)
- Sjaak Pouwels
- Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, NLD
| | | | | | - Anne Rutten
- Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, NLD
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