Fístula nasal de líquido cefalorraquídeo post-traumática. Resultados de la implementación de un protocolo de trabajo / Post-traumatic cerebrospinal fluid nasal leak. Results of the implementation of a work protocol

Introducción: Los pacientes con fracturas de base de cráneo anterior post traumatismo encéfalo-craneano tienen alto riesgo de fístula de líquido céfalo-raquídeo por las fosas nasales. Es importante el manejo oportuno y apropiado, evitando así complicaciones; razón por la cual se desarrolló el "protocolo HP" para su tratamiento quirúrgico. Objetivo: Comunicar la utilidad del "protocolo HP" en el manejo de la fístula de líquido céfalo-raquídeo de la base de cráneo anterior. Materiales y métodos: Estudio transversal retrospectivo con pacientes ≥ 15 años con diagnóstico de fístula de líquido céfalo-raquídeo nasal post traumatismo encéfalo-craneano, desde 1/1/2016 hasta 31/8/2021 que ingresaron al hospital y requirieron cirugía de reparación, con 28 pacientes incluidos, el valor p ˂0,05 (estadísticamente significativo). Resultados: 96,4% hombres, mayoría adultos jóvenes con traumatismo encéfalo-craneano leve; 82,1% presentó fístula de líquido céfalo-raquídeo temprana. Todos requirieron reparación transcraneal frontal, en 67,9% fue bilateral. La reparación antes de los 7 días fue en el 39,3%, 7-21 días en 46,4% y después de 21 días en 14,3% de los casos. Uso de drenaje lumbar continuo: preoperatorio 10,7%, intraoperatorio 60,7%, postoperatorio 46,4%. En el 89,3% la ubicación de la fístula de líquido céfalo-raquídeo intra-quirúrgica fue congruente con la tomografía. Desde el 2020 se sistematizó el manejo de las fístula de líquido céfalo-raquídeo. La recurrencia fue de 10,7% antes del 2020 (posteriormente fue de 0%), asociándose con Glasgow bajo e inicio de fístula de líquido céfalo-raquídeo 7 días post traumatismo encéfalo-craneano (p˂0,05). Complicaciones encontradas: meningitis 28,6%, convulsión 25%, anosmia 14,3%, neumoencéfalo a tensión 7,1% y absceso 3,6%. Mortalidad por fístula de líquido céfalo-raquídeo: 3,6%. Curación 96,4%. Conclusiones: La aplicación del "Protocolo HP" tuvo resultados satisfactorios. La tasa de recurrencia postoperatoria de fístula de líquido céfalo-raquídeo nasal post traumatismo encéfalo-craneano fue 0%(AU)

Background: Patients with anterior skull base fractures after traumatic brain injury have a high risk of cerebrospinal fluid leak through the nostrils. Timely and appropriate management is important, avoiding complications. The "HP protocol" for surgical treatment was developed. Objectives: To communicate the utility of the "HP protocol" in the management of the anterior skull base cerebrospinal fluid leak. Methods: Retrospective cross-sectional study; patients ≥ 15 years old with a diagnosis of nasal cerebrospinal fluid leak after traumatic brain injury, who were admitted at the hospital from 1/1/2016 to 8/31/2021 and required surgery. Included 28 patients, p value ˂0.05 (statistically significant). Results: 96.4% men, mostly young adults with mild traumatic brain injury; 82.1% presented early cerebrospinal fluid leak. All required frontal transcranial repair, in 67.9% it was bilateral. Repair before 7 days was in 39.3%, 7-21 days in 46.4%, and after 21 days in 14.3%. Use of continuous lumbar drainage: preoperative 10.7%, intraoperative 60.7%, postoperative 46.4%. In 89.3%, the location of the intraoperative cerebrospinal fluid leak was consistent with the CT scan. Since 2020, the management of the cerebrospinal fluid leak was systematized. The recurrence was 10.7% before 2020; after it was 0% and associated with low Glasgow and onset of cerebrospinal fluid leak 7 days after traumatic brain injury (p<0.05). Complications: meningitis 28.6%, seizure 25%, anosmia 14.3%, high tension pneumocephalus 7.1% and abscess 3.6%. Cerebrospinal fluid leak mortality: 3.6%. Cure 96.4%. Conclusions: The application of the "HP Protocol" had satisfactory results. The post traumatic brain injury nasal cerebrospinal fluid leak recurrence rate was 0%

Neumoencéfalo, una revisión de literatura / Pneumocephalus, a literature review

El neumoencéfalo corresponde a la presencia de aire intracraneal y, en general, es asintomático y autolimitado. Puede ocurrir posterior a trauma, cirugía craneofacial, defectos congénitos, infección, neoplasia o de forma espontánea. El neumoencéfalo a tensión es una emergencia neuroquirúrgica, en la que se acumula aire intracraneal de forma continua que genera un efecto de masa. Clínicamente, se caracteriza por cefalea y un deterioro neurológico marcado. A pesar de ser poco frecuente, es relevante considerar el neumoencéfalo a tensión como una posible complicación en pacientes con antecedente de neurocirugía y/o cirugía otorrinolaringológica, debido a que es una patología potencialmente grave. El diagnóstico es clínico e imagenológico, y requiere de un alto índice de sospecha. Un manejo oportuno es relevante para prevenir la herniación y la muerte.

Pneumocephalus refers to the presence of air in the cranial cavity, and in general, is self-limited and asymptomatic. It can occur after trauma, craniofacial surgery, due to congenital defects, infection, neoplasia or spontaneously. Tension pneumocephalus is a neurosurgical emergency in which intracranial air accumulates continuously, causing a mass effect. It presents with headache and marked neurological deterioration. Despite being rare, it is relevant to consider tension pneumocephalus as a possible complication in patients with a history of neurosurgery and/or otolaryngology surgery, as it can be life-threatening. Diagnosis requires a high index of suspicion and imagenologic confirmation. Timely management is relevant to prevent herniation and death.

Neumoencéfalo recurrente post quirúrgico, a raíz de dos casos / Post-surgical late pneumoencephalus, based on two cases

El neumoencéfalo es una patología que comúnmente se presenta después de cirugía neuroquirúrgica y ocasionalmente endonasal. Estos se suelen manejar de manera conservadora, sin embargo, se pueden asociar a distintas etiologías las cuales los hacen recurrir. En este reporte presentamos dos casos de neumoencéfalo tardío post quirúrgico asociado a fístulas de LCR de bajo flujo, donde se discute su clínica, etiología y manejo posterior.

Pneumocephalus is a pathology that commonly occurs after endonasal surgery, these are usually managed conservatively, however they can be associated with different etiologies which make them recur. In this report we present two cases of post-surgical late pneumocephalus associated with low-flow CSF fistulae, where its symptoms, etiology, and subsequent management are discussed.

Pneumoncoccal Meningitis Presenting with Ventriculitis and Pneumocephalus

No abstract available.

A Case of Orbital Apex Syndrome with Central Retinal Artery and Vein Occlusion Following Trauma

PURPOSE: To report a case of orbital apex syndrome (OAS) combined with central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) following blunt trauma. CASE SUMMARY: A 4-year-old female visited the hospital following a traffic accident. She was admitted because of multiple fractures of the skull and pneumocephalus. On day 5, she was referred to us with decreased visual acuity in her right eye. Her initial visual acuity was hand motions in the right eye and 0.8 in the left eye. The right eye showed a dilated pupil, ptosis, and total ophthalmoplegia, and the left eye showed limited abduction. A fundus examination revealed multiple retinal hemorrhages, tortuous veins, and an edematous white retina with a cherry-red spot in the right eye. Brain magnetic resonance imaging revealed an entrapped right optic nerve because of bony fragments in the orbital apex. The patient was diagnosed with OAS accompanied by CRAO and CRVO in the right eye, and with traumatic abducens nerve palsy in the left eye. After 6 months, the visual acuity was hand motions, and the fundus examination showed absorbed retinal hemorrhages, pale discs, and general retinal thinning of the right eye. Ptosis of the right eye and extraocular muscle movement of both eyes were improved. CONCLUSIONS: Combined CRAO and CRVO following trauma is very rare and is even more rarely associated with OAS. It is important for clinicians to be aware of the potential for central retinal vessel occlusions and OAS in cases of blunt ocular trauma.

Complication of epiduroscopy: a brief review and case report

Epiduroscopy is defined as a percutaneous, minimally invasive endoscopic investigation of the epidural space. Periduroscopy is currently used mainly as a diagnostic tool to directly visualize epidural adhesions in patients with failed back surgery syndrome (FBSS), and as a therapeutic action in patients with low back pain by accurately administering drugs, releasing inflammation, washing the epidural space, and mechanically releasing the scars displayed. Considering epiduroscopy a minimally invasive technique should not lead to underestimating its potential complications. The purpose of this review is to summarize and explain the mechanisms of the side effects strictly related to the technique itself, leaving aside complications considered typical for any kind of extradural procedure (e.g. adverse reactions due to the administration of drugs or bleeding) and not fitting the usual concept of epiduroscopy for which the data on its real usefulness are still lacking. The most frequent complications and side effects of epiduroscopy can be summarized as non-persistent post-procedural low back and/or leg discomfort/pain, transient neurological symptoms (headache, hearing impairment, paresthesia), dural puncture with or without post dural puncture headache (PDPH), post-procedural visual impairment with retinal hemorrhage, encephalopathy resulting in rhabdomyolysis due to a dural tear, intradural cyst, as well as neurogenic bladder and seizures. We also report for first time, to our knowledge, a case of symptomatic pneumocephalus after epiduroscopy, and try to explain the reason for this event and the precautions to avoid this complication.

A Case of Sensorineural Hearing Loss and Vertigo during Epidural Nerve Block / 대한평형의학회지

Epidural anesthesia has significantly advanced in neuraxial anesthesia and analgesia. It is used for surgical anaesthesia and treatment of chronic pain. Hearing loss during or after epidural anesthesia is rare, and it is known to occur by the change of the intracranial pressure. Cerebrospinal fluid is connected with perilymph in the cochlear and vestibule that is important to hearing and balance. If the intracranial pressure is abruptly transferred to the inner ear, perilymph can be leak, that called perilymphatic fistula, dizziness, and hearing loss can occur suddenly. We report a 65-year-old woman who presented with acute onset dizziness and hearing loss during the epidural nerve block for back pain, wherein we speculated a possibility of perilymphatic fistula as the mechanism of hearing loss and dizziness. The mechanism of dizziness and hearing loss was suspected with perilymphatic fistula.

A Case of Frontoethmoidal Mucopyocele Combined with Cerebrospinal Fluid Leak and Complicated Tension Pneumocephalus after Marsupialization

After the trauma of frontoethmoidal sinus, post-traumatic mucocele may occur. Surgical removal of the lesions rarely produces cerebrospinal fluid (CSF) leakage and even delayed tension pneumocephalus. We experienced a case of fronto-ethmoid mucocele complicated with peri-operative CSF leakage and post-operative tension pneumocephalus which was improved by conservative treatment. It is imperative to take into account the potential for tension pneumocephalus when a patient suffers from severe headache after sinus surgery.

Traumatic cerebrospinal fluid leakage following septorhinoplasty

Septoplasty/septorhinoplasty is a common ear, nose and throat procedure offered for those patients with deviated septum who are suffering from nasal obstruction and functional or cosmetic problems. Although it is a basic and simple procedure, it could lead to catastrophic complications including major skull base injuries which result in cerebrospinal fluid (CSF) leaks. We describe two different cases of traumatic CSF leaks following septoplasty/septorhinoplasty at two different sites. The first patient suffered a CSF leak following septoplasty and presented to Alexandria University Hospital. The leak was still active at presentation and identified as coming from a defect in the roof of the sphenoid sinus and was repaired surgically. The second patient presented 4 days after her cosmetic septorhinoplasty with a CSF leak and significant pneumocephalus. She was managed conservatively. Understanding the anatomical variations of the paranasal sinuses and implementing proper surgical techniques are crucial in preventing intracranial complications when performing either septoplasty or septorhinoplasty. A good quality computed tomography of the nose and paranasal sinuses is a valuable investigation to avoid major complications especially CSF leaks following either procedure.

Post-traumatic Tension Pneumoventricle: Case Report

Pneumoventricle and liquoric fistula are possible complications of traumatic brain injury (TBI), the main cause of morbimortality related to trauma in Brazil. Liquoric fistulae are more common after direct trauma with skull base fractures. However, pneumoventricle is rare and occurs due to excessive cerebrospinal fluid (CSF) drainage in the presence of a poorly compliant ventricle system, resulting in the influx of air to its interior. The pathophysiology of tension pneumoventricle remains uncertain. However, the traumatic cause is certain andmultiple bone fractures of the face and liquoric fistula may contribute to the process. If symptomatic, the tension pneumoventricle can cause rapid clinical deterioration. The authors aim to report a rare case of post-TBI tension pneumoventricle with complete resolution and without signs of recurrence of the liquoric fistula after surgical treatment.

Some peculiar lesions of traumatic brain injuries encountered in our practice with brief discussion-imaging manuscript

The advent of neuroimaging like computed tomography and magnetic resonance imaging has facilitated the diagnosis of traumatic brain injuries. Emphasizing certain diagnostic features of some peculiar traumatic brain injuries. The following lesions of traumatic brain injuries were pictorially depicted, namely Tension pneumocephalus, Blow out orbit, Bilateral subacute subdural haematomata, Acute-onchronic subdural haematoma, Middle cranial fossa acute epidural haematoma, Traumatic basal ganglial haematoma and Acute intra-ventricular haematoma. Mount Fuji sign is typical of tension pneumocephalus while herniation of extra-ocular muscles into the maxillary sinus is diagnostic of blowout orbit. Rabbit ear appearance is observable in bilateral subacute subdural haematomata

Intractable intraoperative brain herniation secondary to tension pneumocephalus: a rare life-threatening complication during drainage of subdural empyema / Herniação cerebral intratável secundária a pneumoencéfalo hipertensivo no intraoperatório: uma complicação rara com risco para a vida durante a drenagem de empiema subdural

Abstract Tension pneumocephalus is rare but has been well documented following trauma and neurosurgical procedures. It is a surgical emergency as it can lead to neurological deterioration, brainstem herniation and death. Unlike previous cases where tension pneumocephalus developed postoperatively, we describe a case of intraoperative tension pneumocephalus leading to sudden, massive open brain herniation out of the craniotomy site. The possible causative factors are outlined. It is imperative to rapidly identify possible causes of acute intraoperative brain herniation, including tension pneumocephalus, and institute appropriate measures to minimize neurological damage.

Resumo O pneumoencéfalo hipertensivo é raro, mas foi bem documentado após trauma e procedimentos neurocirúrgicos. Trata-se de uma emergência cirúrgica porque pode levar à deterioração neurológica, herniação do tronco cerebral e morte. Ao contrário de casos anteriores, nos quais o pneumoencéfalo hipertensivo se desenvolveu no pós-operatório, descrevemos um caso de pneumoencéfalo hipertensivo desenvolvido no período intraoperatório que levou a uma herniação cerebral súbita, maciça e aberta para fora do local da craniotomia. Os possíveis fatores causais são destacados. É imperativo identificar rapidamente as possíveis causas da herniação cerebral aguda no intraoperatório, incluindo o pneumoencéfalo hipertensivo, e instituir medidas apropriadas para minimizar os danos neurológicos.

Disc Herniation and Cyst Gas: A Rare Association Causing Radicular Compression

Introduction Intraspinal gas is a common clinical finding, but an epidural gas pseudocyst in association with lateral disc herniation compressing a nerve root is an exceptional observation. Case Report A 49-year-old man was admitted to our department presenting with sciatica. The neurological examination demonstrated moderate lumbar pain without neurological deficit. A lumbosacral computed tomography showed the presence of degenerated disc herniation and epidural gas collection. Discussion The pathological association between the cyst and the hernia is probably due to the migration of gas pumped from the intervertebral space through a breaking point or lower in the annulus fibrosis, involving its contiguity with the herniated disc. Conclusion An association between a disc herniation and a gas pseudocyst can be a cause of sciatica.

Introdução O gás intraespinal é um achado clínico comum, mas um pseudocisto epidural de gás associado a herniação discal lateral comprimindo uma raiz nervosa é uma observação excepcional. Relato de caso Um homem de 49 anos de idade foi admitido em nosso departamento apresentando sintomas de ciática. O exame neurológico demonstrou dor lombar moderada sem déficit neurológico. A tomografia computadorizada lombossacral mostrou presença de hérnia discal degenerada e coleta epidural de gás. Discussão A associação patológica entre o cisto e a hérnia é provavelmente devida à migração do gás bombeado do espaço intervertebral através de um ponto de ruptura ou menor na fibrose do anel, envolvendo a sua contiguidade com o disco herniado. Conclusão Uma associação entre uma hérnia de disco e um pseudocisto de gás pode ser uma das causas de ciática.

A Rare Complication of Lumbar Spinal Surgery: Pneumocephalus / 대한신경손상학회지

A 25-year-old male patient with severe thigh and right side pain was presented. In the lumbar magnetic resonance images, there was a contrasting spinal cord tumor image with 1 cm in diameter at the level of the L3 vertebra. The patient was operated and the tumor was totally removed. All the pain of the patient recovered. The patient's postoperative two days were very comfortable and the patient was early mobilized. On the third postoperative day, the patient complained of severe headache, nausea and vomiting. Immediate cranial computed tomography (CT) images was performed. Cerebral pneumocephalus was present in CT. The patient was treated with definite bed rest and plenty of fluid replacement. After three days, the patient's complaints were completely improved. This improvement was confirmed by performing a cerebral CT scan. In the formation of pneumocephalus, air is compressed into the intradural space during operation and this passes to the cerebral space. Definite bed rest, abundant fluid replacement and, in addition, highly inspired oxygen therapy are sufficient to correct the condition.

Proper Management of Posttraumatic Tension Pneumocephalus / 대한신경손상학회지

Pneumocephalus is commonly seen after craniofacial injury. The pathogenesis of pneumocephalus has been debated as to whether it was caused by ball valve effect or combined episodic increased pressure within the nasopharynx on coughing. Discontinuous exchange of air and cerebrospinal fluid due to “inverted bottle” effect is assumed to be the cause of it. Delayed tension pneumocephalus is not common, but it requires an active management in order to prevent serious complication. We represent a clinical case of a 57-year-old male patient who fell down from 3 m height, complicated by tension pneumocephalus on 5 months after trauma. We recommend a surgical intervention, but the patient did not want that so we observe the patient. The patient was underwent seizure and meningitis after 7 months after trauma, he came on emergency room on stupor mentality. Tension pneumocephalus may result in a neurologic disturbance due to continued air entrainment and it significantly the likelihood of intracranial infection caused by continued open channel. Tension pneumocephalus threat a life, so need a neurosurgical emergency surgical intervention.

Cerebrospinal fluid infection after lumbar nerve root steroid injection: a case report / 대한마취과학회지

A 45-year-old woman was admitted due to severe headache and neck stiffness. She had visited a local clinic for back pain and received a lumbar nerve root steroid injection 10 days before admission. Computed tomography and magnetic resonance imaging showed psoas abscess, pneumocephalus, and subdural hygroma. She was diagnosed with psoas abscess and meningitis. The abscess and external ventricle were drained, and antibiotics were administered. Unfortunately, the patient died on hospital day 19 due to diffuse leptomeningitis. Lumbar nerve root steroid injections are commonly used to control back pain. Vigilance to "red flag signs" and a rapid diagnosis can prevent lethal outcomes produced by rare and unexpected complications related to infection. Here, we report a case of fatal meningitis after infection of the cerebrospinal fluid following a lumbar nerve root steroid injection.

Pneumocephalus Following Combined Spinal Epidural Anaesthesia for Total Knee Arthroplasty: A

The authors describe a case of pneumocephalus following epidural anaesthesia for total knee arthroplasty. Multiple attempts in locating the epidural space for the anaesthesia and the use of loss of resistance to air (LORA) technique were identified as the source of air entry. Supportive management was given including high flow oxygenation therapy and spontaneous reabsorption of air was noted five days after surgery. The presence of pneumocephalus should be kept in mind if patient develops neurological complications postoperatively following epidural anaesthesia.

Pneumocephalus after Interlaminar Lumbar Epidural Block / 대한정형외과학회잡지

Lumbar epidural block using a “loss of resistance” technique (LORT) with air can potentially cause pneumocephalus. Herein, we present a pneumocephalus that occurred after an epidural block. A 58-year-old male patient underwent an interlaminar lumbar epidural block using a LORT with air for L4–5 disc herniation. After the block, the patient complained of headache, vomiting, and truncal myoclonus. For further evaluation, a brain computed tomography was performed, and pneumocephalus was finally diagnosed. The patient underwent conservative treatment and recovered without any complications. He was discharged on the 11th day after the block.