RESUMO
BACKGROUND: Pneumocephalus (PNC) is the presence of air in the intracranial cavity. The most frequent cause is trauma, but there are many other etiological factors, such as surgical procedures. PNC with compression of frontal lobes and the widening of the interhemispheric space between the tips of the frontal lobes is a characteristic radiological finding of the "Mount Fuji sign." In addition to presenting our own case, we reviewed the most relevant clinical features, diagnostic methods, and conservative management for this condition. CASE DESCRIPTION: A 74-year-old male was diagnosed with meningioma of olfactory groove several years ago. After no improvement, surgery of the left frontal craniotomy keyhole type was conducted. A computed tomography (CT) scan of the skull performed 24 h later showed a neuroimaging that it is described as the silhouette of Mount Fuji. The treatment was conservative and used continuous oxygen for 5 days. Control CT scan demonstrated reduction of the intracranial air with normal brain parenchyma. CONCLUSION: The review of the literature, we did not find any cases of tension pneumocephalus documented previously through a supraorbital keyhole approach. There are a few cases reported of patients with Mount Fuji signs that do not require surgical procedures. The conservative treatment in our report leads to clinical and radiological improvement as well as a reduction in hospitalization time.
RESUMO
OBJECT: Bolivia, one of the poorest countries in the world, ranks 108th on the 2013 Human Development Index. With approximately 1 neurosurgeon per 200,000 people, access to neurosurgery in Bolivia is a growing health concern. Furthermore, neurosurgery in nonindustrialized countries has been considered both cost-prohibitive and lacking in outcomes evaluation. A non-governmental organization (NGO) supports spinal procedures in Bolivia (Solidarity Bridge), and the authors sought to determine its impact and cost-effectiveness. METHODS: In a retrospective review of prospectively collected data, 19 patients were identified prior to spinal instrumentation and followed over 12 months. For inclusion, patients required interviewing prior to surgery and during at least 2 follow-up visits. All causes of spinal pathology were included. Sixteen patients met inclusion criteria and were therefore part of the analysis. Outcomes measured included assessment of activities of daily living, pain, ambulation, return to work/school, and satisfaction. Cost-effectiveness was determined by cost-utility analysis. Utilities were derived using the Health Utilities Index. Complications were incorporated into an expected value decision tree. RESULTS: Median (± SD) preoperative satisfaction was 2.0 ± 0.3 (on a scale of 0-10), while 6-month postoperative satisfaction was 7 ± 1.4 (p < 0.0001). Ambulation, pain, and emotional disability data suggested marked improvement (56%, 69%, and 63%, respectively; p = 0.035, 0.003, and 0.006). Total discounted incremental quality-adjusted life year (QALY) gain was 0.771. The total discounted cost equaled $9036 (95% CI $8561-$10,740) at 2 years. Computing the incremental cost-effectiveness ratio resulted in a value of $11,720/QALY, ranging from $9220 to $15,473/QALY in a univariate sensitivity analysis. CONCLUSIONS: This NGO-supported spinal instrumentation program in Bolivia appears to be cost-effective, especially when compared with the conventional $50,000/QALY benchmark and the WHO endorsed country-specific threshold of $16,026/QALY. However, with a gross domestic product per capita in Bolivia equaling $4800 per year and 30.3% of the population living on less than $2 per day, this cost continues to appear unrealistic. Additionally, the study has several significant limitations, namely its limited sample size, follow-up period, the assumption that patients not receiving surgical intervention would not make any clinical improvement, the reliance on the NGO for patient selection and sustainable practices such as follow-up care and ancillary services, and the lack of a randomized prospective design. These limitations, as well as an unclear understanding of Bolivian willingness-to-pay data, affect the generalizability of the study findings and impede widespread economic policy reform. Because cost-effectiveness research may inevitably direct care decisions and prove that an effort such as this can be cost saving, a prospective, properly controlled investigation is now warranted.