Use of oxygen therapy for pneumocephalus: a systematic review.

Pneumocephalus is the pathologic collection of air in the intracranial cavity. In sufficient volumes, it can contribute to symptoms ranging from headaches to death. For conservative treatment, oxygen use is commonplace. Although this is an accepted tenet of clinical practice, it is not necessarily founded on robust trials. An electronic search of databases EMBASE and MEDLINE and the Cochrane Library was undertaken as per the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. Three articles were included. Although the modes of oxygen delivery were heterogenous (non-rebreather versus endotracheal versus hyperbaric chamber), all studies concluded favorably on the use of oxygen therapy for increased reabsorption of pneumocephalus.

Air travel with pneumocephalus: a systematic review.

INTRODUCTION: Concerns arise when patients with pneumocephalus engage in air travel. How hypobaric cabin pressure affects intracranial air is largely unclear. A widespread concern is that the intracranial volume could relevantly expand during flight and lead to elevated intracranial pressure. The aim of this systematic review was to identify and summarise models and case reports with confirmed pre-flight pneumocephalus. METHODS: The terms (pneumocephalus OR intracranial air) AND (flying OR fly OR travel OR air transport OR aircraft) were used to search the database PubMed on 30 November 2021. This search returned 144 results. To be included, a paper needed to fulfil each of the following criteria: (i) peer-reviewed publication of case reports, surveys, simulations or laboratory experiments that focussed on air travel with pre-existing pneumocephalus; (ii) available in full text. RESULTS: Thirteen studies met the inclusion criteria after title or abstract screening. We additionally identified five more articles when reviewing the references. A notion that repeatedly surfaced is that any air contained within the neurocranium increases in volume at higher altitude, much like any extracranial gas, potentially resulting in tension pneumocephalus or increased intracranial pressure. DISCUSSION: Relatively conservative thresholds for patients flying with pneumocephalus are suggested based on models where the intracranial air equilibrates with cabin pressure, although intracranial air in a confined space would be surrounded by the intracranial pressure. There is a discrepancy between the models and case presentations in that we found no reports of permanent or transient decompensation secondary to a pre-existing pneumocephalus during air travel. Nevertheless, the quality of examination varies and clinicians might tend to refrain from reporting adverse events. We identified a persistent extracranial to intracranial fistulous process in multiple cases with newly diagnosed pneumocephalus after flight. Finally, we summarised management principles to avoid complications from pneumocephalus during air travel and argue that a patient-specific understanding of the pathophysiology and time course of the pneumocephalus are potentially more important than its volume.

The Complication of Tension Pneumocephalus After Septoplasty.

ABSTRACT: This paper presents a case of tension pneumocephalus with severe headache 2 days after septoplasty surgery. In such cases, endoscopic sinus surgery (ESS) or open approach can be used for repair of the defect. However, pneumocephalus, especially caused by minor defects, improves spontaneously with conservative treatment. In our case, the pneumocephalus was responsive to conservative treatment with bed rest, head elevation. His examinations in the 3rd and 8th months after discharge were uneventful and CT scan revealed no signs of pneumocephalus. In severe headaches developing after septoplasty, the possibility of intracranial complications should be evaluated. Simple conservative treatment should be tried before surgery, but then the patient should be examined at regular intervals.

Occurrence and management of postoperative pneumocephalus using the semi-sitting position in vestibular schwannoma surgery.

BACKGROUND: The semi-sitting position in neurosurgical procedures is still under debate due to possible complications such as venous air embolism (VAE) or postoperative pneumocephalus (PP). Studies reporting a high frequency of the latter raise the question about the clinical relevance (i.e., the incidence of tension pneumocephalus) and the efficacy of a treatment by an air replacement procedure. METHODS: This retrospective study enrolled 540 patients harboring vestibular schwannomas who underwent posterior fossa surgery in a supine (n = 111) or semi-sitting (n = 429) position. The extent of the PP was evaluated by voxel-based volumetry (VBV) and related to clinical predictive factors (i.e., age, gender, position, duration of surgery, and tumor size). RESULTS: PP with a mean volume of 32 ± 33 ml (range: 0-179.1 ml) was detected in 517/540 (96%) patients. The semi-sitting position was associated with a significantly higher PP volume than the supine position (40.3 ± 33.0 ml [0-179.1] and 0.8 ± 1.4 [0-10.2], p < 0.001). Tension pneumocephalus was observed in only 14/429 (3.3%) of the semi-sitting cases, while no tension pneumocephalus occurred in the supine position. Positive predictors for PP were higher age, male gender, and longer surgery duration, while large (T4) tumor size was established as a negative predictor. Air exchange via a twist-drill was only necessary in 14 cases with an intracranial air volume > 60 ml. Air replacement procedures did not add any complications or prolong the ICU stay. CONCLUSION: Although pneumocephalus is frequently observed following posterior fossa surgery in semi-sitting position, relevant clinical symptoms (i.e., a tension pneumocephalus) occur in only very few cases. These cases are well-treated by an air evacuation procedure. This study indicates that the risk of postoperative pneumocephalus is not a contraindication for semi-sitting positioning.

Oxygen Therapy with High-Flow Nasal Cannula as an Effective Treatment for Perioperative Pneumocephalus: Case Illustrations and Pathophysiological Review.

Pneumocephalus (PNC) is a condition in which when air is trapped inside the intracranial vault. The causes are varied, but include trauma and intracranial surgery. Treatment of PNC typically consists of augmenting patient oxygenation with the attempt of washing out pulmonary nitrogen, creating a gradient in which nitrogen in the intracranial air bubble diffuses out of the lungs via the blood. Though several high flow methods have been tested, the ideal mode of oxygenation has not fully been investigated. Here we present 3 cases of post-operative PNC who we felt were symptomatic from PNC. With administration of high-flow nasal cannula (HFNC), all patients improved both clinically and radiographically within a few hours, faster than in both anecdotal experience and published trials. Due to its steady FiO2 administration, positive pressure, comfort, and low side-effect profile, HFNC may be the ideal mode of oxygen delivery in PNC. We present a review of the physiology of PNC and the characteristics of several oxygen delivery systems to build a case for HFNC in this disease process.

Acute Management of Tension Pneumocephalus in a Pediatric Patient: A Case Report.

BACKGROUND: Tension pneumocephalus is a rare but life-threatening condition in which air gains entry into the cranium and exerts mass effect on the brain, resulting in increased intracranial pressure. It occurs most frequently secondary to head trauma, particularly to the orbits or sinuses. CASE REPORT: A 13-year-old male sustained facial trauma from a motor vehicle collision and was found to have tension pneumocephalus on computer tomography. The patient underwent immediate rapid sequence intubation without preceding positive pressure ventilation in the emergency department. At the time of his craniotomy, the tension pneumocephalus was found to have resolved and he went on to have a complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Any patient with facial or head trauma and pneumocephalus is at risk for the potential development of tension pneumocephalus. When present, we advocate that aggressive definitive airway management by rapid sequence intubation without preceding positive pressure ventilation and early surgical management should be prioritized.

Air Transport of a Patient With Impending Cerebral Herniation From Tension Pneumocephalus.

Tension pneumocephalus is a rare but dangerous complication of craniotomy, sinus surgery, and traumatic cranial injury. Compared with simple pneumocephalus, which often resolves spontaneously over the course of a few days, tension pneumocephalus tends to increase with ongoing cerebrospinal fluid leak and requires immediate neurosurgical treatment to prevent cerebral herniation. Air transport of patients with tension pneumocephalus for neurosurgical care entails a risk of neurologic worsening because of changes in ambient air pressure with altitude and cabin pressurization. We describe a case in which severe symptomatic tension pneumocephalus developed after endoscopic endonasal sinus surgery in an 81-year-old man. The patient lived in a remote area and required air transport for medical care. Pretreatment with oxygen therapy and maintaining the patient in a flat supine position rapidly improved his neurologic status, allowing transportation without incidence. A recommendation was also made to the medical transport team to fly at the lowest possible altitude. Specific precautions may enable safe transport of these critically ill patients for treatment, although further data must be obtained before these can be definitively recommended.

[CASE REPORT: PNEUMOCEPHALIA AFTER EPIDURAL ANESTHESIA FOR HIP REPLACEMENT SURGERY.]

Lumbar epidural anesthesia is a commonly used anaesthetic technique for trauma and orthopedic surgery of the lower extremities. One of the rare complications of epidural anesthesia is pneumocephalia. The article describes a case of pneumocephalia after epidural anesthesia performed for anesthetic management of the hip replacement surgery. Eight hours after the epidural anesthesia the patient had depression of consciousness progressing to coma. Computed tomog- raphy of the brain detected pneumocephalia. Symptomatic treatment provided a regression of neurological deficit. CT scanning of the brain on the 8th postoperative day showed resolution ofpneumocephalia. The patient was discharged from the hospital on the 15th day after surgery. The most probable mechanism explaining this case ofpneumocephalia development is the theory ofa the inverted bottle).

[Intracranial Hemorrhage and Pneumocephalus after Spinal Cord Tumor Resection: A Case Report].

A 75-year-old woman was scheduled for spinal cord tumor resection. General anesthesia was induced and maintained using propofol, remifentanil and fentanyl. Aside from fluctuations in intraoperative blood pres- sure, the surgery was uneventful, but emergence from anesthesia was delayed and the patient showed partial paralysis. Emergent brain CT revealed multiple intracranial hemorrhages and pneumocephalus. Since a large amount of fluid was observed from the drainage tube at the surgical site, loss of cerebrospinal fluid and subsequent low intracranial pressure were considered to be the cause of the hemorrhage and pneumocepha- lus. Intracranial hemorrhage and pneumocephalus are rare complications after spinal surgery, but they can lead to serious neurological dysfunction. Dural tear and/or excessive drainage are considered to be the causes of these complications, and careful observation of the property, amount and rate of drainage is there- fore warranted.

Preventing Shift from Pneumocephalus During Deep Brain Stimulation Surgery: Don't Give Up the 'Fork in the Brain'.

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.

Pneumocephalus due to middle ear inflation.

Middle ear inflation procedures are widely used for diagnosis and treatment of middle ear disease. Although its values are controversial, it is used in testing eustachian tube function or treating middle ear diseases, such as effusions or atelectasis. Physicians rarely experience complications with this procedure; thus, complications following middle ear inflation are rare. Known adverse effects of middle ear inflation procedures include pneumocele, brain hematoma, and air embolization. Pneumocephalus is one of the rare complications of middle ear inflation. It is a potentially fatal condition, and although middle ear inflation is used around the world, it is rarely encountered by general physicians and even otolaryngologists. We report a case of pneumocephalus that occurred immediately following a middle ear inflation procedure using a pneumatic otoscope with myringotomy (paracentesis).

Tension pneumocephalus: a case report with review of literature.

Tension Pneumocephalus (PC) was described 50 years ago. A case of pneumocephalus (PC) following cervical epidural injection in a 50-year-old male worsened by air travel and manifested as tension pneumocephalus, confirmed by advanced neuroimaging, is reported for the first time along with literature review. The patient underwent emergent frontal burr hole evacuation and air gushed under pressure. The patient recovered well and is stable during a follow-up of 12 months. Presenting features and clinical course along with Mount Fuji sign, Peaking sign, and air bubble sign observed in this case are described. Also, the importance of considering neurosurgical and spinal procedures leading to PC have to be considered by practitioners before issuing fitness certificate before air travel, as PC is likely to get transformed to tension PC and can cause an in-flight emergency.

A case report of diffuse pneumocephalus induced by sneezing after brain trauma.

Pneumocephalus is the presence of air in the cranial vault. The common etiologies of pneumocephalus are brain trauma and cranial surgery. We report a case of a 26-year-old man with brain trauma who developed diffuse pneumocephalus after sneezing. CT scan was performed on arrival, and the image showed subarachnoid hemorrhage without pneumocephalus. On the seventh day after a big sneeze brain CT scan was re-performed, which showed pneumocephalus. After another ten days of treatment, the patient was discharged without any symptoms.

Pneumocephalus as result of nonsurgical peri-implantitis treatment with an air-polishing device for submucosal debridement-A case report.

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.

Hyperbaric oxygen therapy in the treatment of pneumocephalus associated with epidural block: case report.

INTRODUCTION: Pneumocephalus is a rare neuraxial blockade complication, which can be associated with severe neurologic changes. CLINICAL CASE: A 51-year-old patient was submitted to left total knee arthroplasty. Postoperatively, a pneumocephalus associated with decreased consciousness was diagnosed as a complication of the epidural analgesia. The treatment used was Hyperbaric Oxygen Therapy (HBOT) due to the severity of symptoms. Just after one session of HBOT, there was nearly full pneumocephalus resorption and significant clinical recovery. CONCLUSION: This case report enables anesthesiologists to recognize HBOT as a therapeutic option to be considered when treating severe cases of pneumocephalus.