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

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

Spontaneous, Intrasphenoidal Rupture of Ecchordosis Physaliphora with Pneumocephalus Captured During Serial Imaging and Clinical Follow-Up: Pathoanatomic Features and Management.

BACKGROUND: Ecchordosis physaliphora (EP) is a congenital, uniformly asymptomatic, hamartomatous lesion of the primitive notochord. Herein we report, to our knowledge, the first credible case report of unprovoked intrasphenoidal rupture resulting in recurrent pneumocephalus and cerebrospinal fluid leak, definitively captured over serial imaging during clinical and radiologic surveillance. CASE DESCRIPTION: A 68-year old woman with Marfan syndrome presented to the emergency department with the worst headache of her life. Imaging demonstrated extensive pneumocephalus and revealed a small, dorsal midline clival lesion consistent with EP and a transsphenoidal defect. Remote imaging encounters confirmed typical EP without pneumocephalus or cortical defect, and an uneventful clinical course years preceding presentation. Over the ensuing months during neurosurgical follow-up, the patient reported recurrent headaches, imbalance, and unprovoked clear rhinorrhea. Further imaging demonstrated an apparently enlarging transsphenoidal defect which was managed by endoscopic transnasal resection and nasoseptal flap. Pathologic evaluation confirmed the diagnosis of EP and chronic dural defect. CONCLUSIONS: This represents, to our knowledge, the first unambiguous example of spontaneous EP rupture and recurrent pneumocephalus captured over serial imaging. The case further underscores rare but potentially significant complications of EP and highlights management options.

Frontotemporal dementia: an unusual cause.

Intracerebral pneumocephalus is commonly associated with head and facial trauma, ear infection, tumors and surgical interventions. Osteomas are relatively common, benign tumors that occur mainly in the paranasal sinuses, the frontal sinus in particular. Pneumocephalus has been commonly reported with frontal osteoma but isolated presentation as frontotemporal dementia is uncommon. Patient was admitted with complaints of change of behavior and forgetfulness for the last one year. He had progressively become more apathetic and presented with behavioral abnormalities. General physical examinations were within normal limits including the motor and sensory system although neuropsychiatry assessments were below the average level, with features of dementia. Further, MRI brain revealed pneumocephalus in bilateral frontal lobe. CT cisternography revealed a well defined lobulated densely sclerotic lesion of approximate size 20 × 17 × 27mm transverse and cranio-caudal axis respectively arising from right ethmoid sinus. Clinically, the association of pneumocephalus and isolated presentation as frontotemporal dementia has not been described to the best of our knowledge. A single case has been described with ethmoid osteoma. Radiological features were suggestive of osteoid osteoma. The uniqueness of the case is the development of dementia with frontotemporal involvement and resemblance with Frontotemporal Dementia. This is the only case with dementia and pneumocephalus (secondary to osteoid osteoma) to best of our knowledge.

First Case Report of Bilateral Spontaneous Otogenic Pneumocephalus.

BACKGROUND: Pneumocephalus is commonly associated with cranial trauma including surgical interventions. Spontaneous pneumocephalus on the other hand is a rare diagnosis. Reported cases were predominantly unilateral. We report a unique case of a bilateral spontaneous pneumocephalus probably related to a bilateral tegmen defect related to repeated Politzer maneuvers. CASE DESCRIPTION: A 78-year-old man suffered from vertigo, tinnitus, instability, and mild expressive aphasia. In the past 12 weeks before clinical deterioration he underwent series of Politzer maneuvers performed for repetitive inflammation of upper respiratory tract with otitis media. Brain computed tomography revealed a large bilateral collection of intracranial air with associated tegmen defects. Primarily, surgical revision of the middle fossa and multilayer reconstruction of the dura and skull base defect on the left side was performed. After 5 days, the other side was reconstructed in a similar way. Postoperative course was uneventful with brisk improvement of symptomatology. Both computed tomography scans undertaken after the first and second surgery showed satisfying regression of intracranial air. CONCLUSIONS: Spontaneous pneumocephalus represents a rare condition often associated with increased middle ear pressure, which can be caused by autoinflation (e.g., Valsalva or Politzer maneuver), sneezing, or coughing. The described case represents a unique presentation of the bilateral spontaneous pneumocephalus associated with bilateral tegmen and dura mater defects managed surgically. Despite its rarity, spontaneous pneumocephalus originating from the temporal bone should be considered as a possible diagnosis in patients with suggestive otologic presentation (e.g., tinnitus, instability, hearing loss) and associated nonspecific neurologic symptomatology.

Pneumocephalus: a rare and life-threatening, but reversible, complication after penetrating lumbar injury.

Pneumocephalus, the presence of intracranial air, is a complication especially seen after neurotrauma or brain surgery. When it leads to a pressure gradient, a so-called tension pneumocephalus, it may require emergency surgery. Clinical symptomatology, especially in young children, does not differentiate between a pneumocephalus and a tension pneumocephalus. An additional CT scan is therefore warranted. Here, we report on a rare case of pneumocephalus after penetrating lumbar injury. Additionally, the pathophysiology of pneumocephalus, as well as its recommendations for diagnosis and treatment, will be elucidated.

Spontaneous pneumocephalus and subdural hemorrhage after sneezing.

Spontaneous pneumocephalus is defined as the presence of air in the absence of intracranial factors. The management of spontaneous pneumocephalus can be conservative or surgical, and surgical intervention could be urgently required if clinical deterioration is rapid. Here, we report a case of pneumocephalus and subdural hemorrhage after sneezing. A 24-year-old male reported to our emergency department with a chief complaint of headache and dizziness. The patient gave a history of onset of headache and dizziness after 2 episodes of heavy sneezing. There was neither a history of recent traumatic episode or previous surgery, nor any signs and symptoms of recent fever or upper respiratory tract infections. Physical examination showed no specific findings. Computed tomography was performed, which showed subdural hemorrhage and PNC in the left occipital lobe, left hemomastoid, and maxillary hemosinus. A neurosurgeon was consulted, who suggested admission in the intensive care unit. An otolaryngologist was then consulted for the left ear otorrhea and hearing impairment. Otoscopic examination showed hemotympanum of the left ear, for which pain control and conservative treatment was suggested. The patient was transferred to general ward 4 days later, since the following brain computed tomography showed resolution of the hemorrhage, and discharged 6 days later because of the improved signs and symptoms. Pneumocephalus and intracranial hemorrhage can occur without a history of trauma or surgery. Special attention is required if headache, dizziness, or other neurologic signs and symptoms occur immediately after sneezing. Intracranial hemorrhage and penumocephalus should be considered in the differential diagnosis.

Unexpected prominent tension pneumosella five years after endoscopic endonasal transsphenoidal surgery.

Tension pneumosella (TP) is a rare entity reported as the invagination of the sphenoid sinus mucosa into the skull base after endonasal transsphenoidal surgery. Few studies have reported on TP, and in these studies, invagination is confined to either the intrasellar or suprasellar area. We encountered a case of unexpected prominent TP toward the intracranial space 5 years after endoscopic endonasal transsphenoidal surgery (EETS) for a nonfunctioning pituitary adenoma. In addition, we present a hypothesis of the underlying mechanism by a pressure gradient change between the extracranial and intracranial space in TP formation. For repair, a pedicled nasal septal flap was fabricated from the remaining part of the septal mucosa, and a pedicled inferior turbinate flap was created. Moreover, the nasal septal cartilage was used as a rigid support for reconstruction, which was useful for preventing TP recurrence. This is the first report of an unexpected prominent TP after EETS. It is important for otorhinolaryngologists and neurosurgeons to be aware of the possibility of TP following EETS. Laryngoscope, 1798-1801, 2018.

Mind-Matter Interactions and the Frontal Lobes of the Brain: A Novel Neurobiological Model of Psi Inhibition.

CONTEXT: Despite a large literature on psi, which encompasses a range of experiences including putative telepathy (mind-mind connections), clairvoyance (perceiving distant objects or events), precognition (perceiving future events), and mind-matter interactions, there has been insufficient focus on the brain in relation to this controversial phenomenon. In contrast, our research is based on a novel neurobiological model suggesting that frontal brain systems act as a filter to inhibit psi and that the inhibitory mechanisms may relate to self-awareness. OBJECTIVE: To identify frontal brain regions that may inhibit psi. DESIGN: We used mind-matter interactions to study psi in two participants with frontal lobe damage. The experimental task was to influence numerical output of a Random Event Generator translated into movement of an arrow on a computer screen to the right or left. Brain MRI was analyzed to determine frontal volume loss. RESULTS: The primary area of lesion overlap between the participants was in the left medial middle frontal region, an area related to self-awareness, and involved Brodmann areas 9, 10, and 32. Both participants showed a significant effect in moving the arrow to the right, i.e., contralateral to the side of primary lesion overlap. Effect sizes were much larger compared to normal participants. CONCLUSIONS: The medial frontal lobes may act as a biological filter to inhibit psi through mechanisms related to self-awareness. Neurobiological studies with a focus on the brain may open new avenues of research on psi and may significantly advance the state of this poorly understood field.

Traumatic pneumocephaly: trapped air from where?

Traumatic pneumocephaly is literally defined as 'air in the head' after trauma. While this phenomenon has been well described in the literature, our case report is unique in describing diffuse pneumocephalus in the subaponeurotic space, subdural space, subarachnoid space, brain and ventricles without a break in the cranial vault: a 26-year-old man fell from a =9 meter scaffolding in a water tower. Following an arduous and delayed extrication, the patient was unresponsive with loss of pulse requiring intubation, cardiopulmonary resuscitation and release of tension pneumothorax with bilateral thoracostomy tubes. Examination remained poor with a Glasgow Coma Scale of 3. Immediate exploratory laparotomy was performed for a small right retroperitoneal haematoma on Focused Assessment with Sonography for Trauma. Postoperative imaging revealed diffuse pneumocephaly without facial fractures. This case presentation explores unusual causes of fistulous connections with the atmosphere that may lead to air trapped in and around the cranial vault.

Isolated, Transient, Pneumocephalus-Induced Oculomotor Neuropathy After Microvascular Decompression of the Trigeminal Nerve.

BACKGROUND: Pneumocephalus is a common radiographic finding after posterior fossa craniotomy. In contrast, cranial neuropathies related to pneumocephalus are extremely rare, with only a handful of previous reports. CASE DESCRIPTION: We present the rare case of a right partial oculomotor mononeuropathy occurring in a 26-year-old woman 4 hours after a microvascular decompression of her right trigeminal nerve. Postoperative imaging revealed pneumocephalus in the interpeduncular cisterns with an air bubble close to the cisternal segment of the right oculomotor nerve, trapped by a fetal right posterior cerebral artery. The patient was placed on 100% Fio2 (fraction of inspired oxygen) and encouraged to remain in the Trendelenburg position. She was discharged with only modest improvement in her pupil-involved partial oculomotor palsy, but she improved over the course of clinical follow-up and her deficit had completely resolved at 6 months. CONCLUSIONS: Cranial neuropathy secondary to pneumocephalus is a rare and usually self-limiting condition. Although high-concentration oxygen therapy hastens resolution of pneumocephalus, recovery from pneumocephalus-related neuropathies may take weeks to months. To properly treat pneumocephalus-induced cranial neuropathies, further studies into the mechanism of injury are needed.

Giant Spontaneous Epidural Pneumatocele: Case Report and Review of the Literature.

BACKGROUND: Pneumocephalus is a commonly encountered finding in neurosurgery in which air displaces intracranial cerebrospinal fluid after cranial surgery or a cerebrospinal fluid leak into paranasal or mastoid sinuses. When an intracranial air collection becomes chronically established in a fixed loculation causing mass effect, pneumatocele is a more appropriate term. We present an unusual case of a spontaneous giant frontotemporal epidural pneumatocele that persisted for more than 1 year before the patient presented for neurological treatment. CASE DESCRIPTION: A 40-year-old man with a remote history of minor head trauma presented with symptoms of headaches, dizziness, and vertigo. Imaging revealed a right giant epidural pneumocephalus secondary to bony dehiscence of the intracranial wall of the mastoid bone. A subtemporal middle fossa approach was performed to repair the mastoid defect with hydroxyapatite, fat graft, and temporalis fascia. The patient was discharged on postoperative day 2 with improvement in his headaches. One month after discharge operative imaging demonstrated complete resolution of his epidural pneumatocele and improvement in his headaches. CONCLUSIONS: This unique case represents the first reported case in the neurosurgical literature of a giant spontaneous epidural pneumatocele occurring in an adult treated with a middle fossa approach with resolution on follow-up imaging.

Effect of Cranial Window Diameter During Deep Brain Stimulation Surgery on Volume of Pneumocephalus.

OBJECTIVE: Successful deep brain stimulation (DBS) surgery necessitates high accuracy in targeting specific intracranial nuclei. Brain shift due to pneumocephalus can contribute to decreased accuracy. Larger burr holes and dural openings may increase pneumocephalus volume due to a greater degree of communication between the subdural space and extracranial air. The aim of this study is to determine if there is a statistically and clinically significant difference in postoperative pneumocephalus volume related to burr hole and durotomy size. MATERIALS AND METHODS: DBS electrodes were surgically implanted through either large (14 mm) burr holes or small (4 mm) twist drill holes. Immediate postoperative computerized tomography (CT) scans of 165 electrode implantations in 85 patients from 2010 to 2013 were retrospectively analyzed. Student's t-test and Mann-Whitney U-test were employed with a threshold of significance set at p ≤ 0.05. RESULTS: No significant difference in pneumocephalus was identified between patients who had implantation of DBS electrodes through 4 mm twist drill holes (N = 71 hemispheres, 12.84 ± 9.79 cm(3) ) and those with large 14 mm burr holes (N = 87, 11.70 ± 7.46 cm(3) , p = 0.42). Volume of pneumocephalus did not correlate with duration of surgery or patient age. The groups did not differ significantly with respect to other aspects of surgical implantation technique or surgical duration. CONCLUSION: While identifying factors that may reduce pneumocephalus volume may be critical to improving stereotactic accuracy and targeting, the current results suggest that burr hole size may not alter the degree of brain shift.

[Supraorbital approach to treat a fronto-orbital fracture with pneumocephaly, a minimal invasive technique]. / Abord supraorbitaire pour traiter une fracture frontale avec pneumocéphalie, une technique peu invasive.

We describe a supraorbital approach through an upper eyebrow skin incision to treat a fronto-orbital fracture with pneumocephaly in a 84-year-old cardiac patient. The clinical and cosmetic results are excellent. This case is illustrated by pre- and postoperative CT-scan and MRI as well as pictures showing the minimal invasive technique.