Delayed Traumatic Tension Pneumocephalus: A Case Report.

ABSTRACT

BACKGROUND: Traumatic tension pneumocephalus is a rare complication after craniofacial fractures that can cause devastating neurologic deficits if not managed promptly and effectively. CASE REPORT A 38-year-old man with no past medical history presented to the Emergency Department (ED) after a motor vehicle crash. He was noted to have an open frontal scalp laceration. Computed tomography (CT) revealed a right frontal subdural hematoma and right medial frontal contusion. There was also a frontal bone fracture extending through the frontal sinus with mild underlying pneumocephalus. He was monitored for cerebrospinal fluid (CSF) leak and was subsequently discharged on postinjury day 9. He re-presented to the ED 14 days post injury with lethargy, confusion, headache, and swelling around his scalp laceration. A CT scan was obtained that revealed a large-volume intraparenchymal pneumocephalus (pneumocerebri) with mass effect and midline shift. The patient was started on 100% oxygen and admitted to the intensive care unit. He was taken to the operating room for evacuation of the pneumocerebri, repair of dural defect, placement of a vascularized pericranial graft, and placement of a lumbar drain. His lumbar drain was removed on postoperative day 3 and he was discharged home neurologically intact on postoperative day 6. At 1 month follow-up he had no evidence of CSF leak and was neurologically intact. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case is presented to increase awareness among emergency physicians that traumatic tension pneumocephalus, and in this case, pneumocerebri, is a rare life-threatening neurosurgical emergency in patients with severe craniofacial fractures after blunt or penetrating head trauma. Early temporizing measures in the ED, such as 100% oxygen via nonrebreather face mask, and urgent neurosurgical consultation are indicated to prevent neurologic deterioration.