Tension Pneumocephalus Secondary to Positive Pressure Ventilation Following Endoscopic Endonasal Skull Base Surgery: Three-Year Follow-Up After Implementation of an Institutional Protocol.

BACKGROUND: Tension pneumocephalus (PMC) is a rare and feared complication following the endonasal endoscopic approach (EEA) to skull base procedures. This is a neurosurgical emergency that requires urgent decompression to avoid catastrophic neurologic damage or death. An avoidable cause is the application of positive pressure ventilation (PPV) in EEA patients for postoperative hypoxia. Our institution implemented a hospital-wide protocol in response to this to identify and manage at-risk patients; this paper aims to identify if this protocol was effective in lowering the rates of tension PMC secondary to PPV. RESULTS: In the 3 years following the implementation of the protocol, 110 patients underwent EEAs, from which 1 case of tension PMC (found to be not secondary to PPV) was identified. This is compared with 2 cases of tension PMC secondary to PPV over the preceding 5 years, out of 406 EEA patients. This constitutes a quantifiable reduction in PPV-related tension PMC in both standard and extended approach EEAs, signifying the effective uptake of the protocol. CONCLUSIONS: We found no cases of tension PMC after PPV following EEA skull base surgery in our institution since the implementation of an institution-wide guideline. This underscores the utility of our simple and cost-effective preventative protocol in reducing the overall rates of tension PMC following the inadvertent postoperative application of PPV. Further research is needed to study the comparative risks and benefits of PPV in the post-EEA patient and thus inform future iterations of the protocol.

Spontaneous Intraventricular Tension Pneumocephalus.

Here, we report a very rare case of spontaneous intraventricular tension pneumocephalus. This case concerns a 40-year-old patient with medical history of a tumor of the pineal region and a secondary hydrocephalus treated by multiple ventriculoperitoneal shunts. He presented in the emergency room because of unusual headaches, nausea, and visual loss. In addition, he reported slight rhinorrhea in the past few weeks. The initial brain computed tomography scan revealed a spontaneous intraventricular tension pneumocephalus. There was no history of recent head trauma and no sign of disconnection of the shunt system. A complementary radiologic assessment including a thin-slice bone computed tomography scan and a radioisotope cisternography revealed an osseous defect and an isotope leakage at the junction between the tegmen tympani and the squamous part of the left temporal bone. A middle cranial fossa surgery was performed to repair the osteo-meningeal breach.

Tension Pneumocephalus With Acute Cerebellar Symptoms Due to an Intradiploic Epidermoid Cyst Eroding the Mastoid Bone.

This case report presents a unique presentation of an intradiploic epidermoid cyst (IDEC) in a 55-year-old female. She presented with acute cerebellar symptoms triggered by a Valsalva maneuver. IDECs are a rare type of intracranial epidermoid cysts. They are benign and have a slow growth pattern that translates into progressively developing symptoms instead of acute symptoms. Symptoms include local deformities, focal neurologic deficits, and pain. This patient developed acute cerebellar symptoms due to erosion of the mastoid bone that created a pathway between the eustachian tube and the intracranial space via the mastoid air cells. Consequently, tension pneumocephalus emerged via a ball-valve effect that caused a significant mass effect in the posterior fossa. Surgical resection of the IDEC and closing of the mastoid air cells resulted in symptom relief by restoring the integrity of the intracranial-extracranial barrier. This case highlights that a higher level of vigilance is warranted for an IDEC in the proximity of aerated bone structures, such as the mastoid air cells and the paranasal sinuses, and that a more proactive approach is advocated.

Recurrent Psychotic Depression Associated with Chronic Subdural Haematoma: A Case Report.

Chronic subdural hematomas (CSDH) with isolated psychiatric presentation are rare. In this paper, we report a case of 77-year-old-female patient who had psychotic depression after repetitive head trauma without any neurological symptoms. The brain magnetic resonance imaging revealed an 20 mm subdural hematoma in the right frontoparietal region and a 7 mm subdural hematoma in the left frontal region. The psychiatric symptoms improved within the first week after evacuation but relapsed with the occurrence of right sided pneumocephalus. In the follow up, with the disappearance of the pneumocephalus, the psychiatric symptoms improved. It should be kept in mind that isolated psychiatric symptoms can be seen due to subdural hematoma and evacuation of the hematoma has an important role in improving the psychiatric symptoms.

Unique Presentation of a Ubiquitous Organism: Capnocytophaga canimorsus Meningitis With Pneumocephalus.

Capnocytophaga canimorsus is a bacterium commonly found in the oral cavities of cats and dogs. Infections are particularly common in immunocompromised patients who have been exposed to bites or come in contact with saliva from these animals. The manifestations of infection include bacteremia, fever, and, rarely, meningitis. Diagnosis is challenging given the bacteria has slow growth on culture media. The organism is susceptible to beta-lactam antibiotics, with higher-generation cephalosporins recommended for treating meningitis. We present a case of a 74-year-old woman with altered mental status and no signs of immunosuppression. She was diagnosed with meningitis caused by Capnocytophaga, with an intriguing finding of pneumocephalus, which is a rare occurrence as per literature review.

Backup Frontal Drainage System for Urgent Tension Pneumocephalus Management After Chronic Subdural Hematoma Surgery: A Retrospective Cohort Study.

OBJECTIVE: To describe a simple variation of burr hole craniostomy for the management of chronic subdural hematoma (CSDH) that uses a frontal drainage system to facilitate timely decompression in the event of tension pneumocephalus and spares the need for additional surgery. METHODS: We conducted a retrospective analysis of 20 patients with CSDH who underwent burr hole craniostomy and 20 patients who underwent the same procedure alongside the placement of a 5 Fr neonatal feeding tube as a backup drainage for the anterior craniostomy. Depending on the situation, the secondary drain stayed for a maximum of 72 hours to be opened and used in emergency settings for drainage, aspiration, or as a 1-way valve with a water seal. RESULTS: The outcomes of 20 patients who underwent this procedure and 20 controls are described. One patient from each group presented tension pneumocephalus. One was promptly resolved by opening the backup drain under a water seal to evacuate pneumocephalus and the other patient had to undergo a reopening of the craniostomy. CONCLUSIONS: The described variation of burr hole craniostomy represents a low-cost and easy-to-implement technique that can be used for emergency decompression of tension pneumocephalus. It also has the potential to reduce reoperation rates and CSDH recurrence. Prospective controlled research is needed to validate this approach further.

Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report.

PURPOSE: Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH). CASE PRESENTATION: An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day. CONCLUSION: TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.

Pneumocephalus resulting from traumatic pneumothorax and brachial plexus avulsion.

Background: Traumatic pneumocephalus is commonly encountered after basal skull fractures and rarely associated with blunt chest trauma. Here, we report a case of pneumocephalus caused by traumatic pneumothorax and brachial plexus avulsion. Case Presentation: A 20-year-old male was admitted to our hospital following a motorcycle accident with complete paralysis of the right upper limb. 2 days later, follow-up computed tomography revealed a slight right pneumothorax, pneumomediastinum around the neck, and intracranial air without skull fracture. Air migrates into the subarachnoid space through a dural tear caused by a brachial plexus avulsion. The pneumocephalus immediately improved after the insertion of a chest drain. Conclusion: Pneumothorax combined with brachial plexus avulsion could lead to pneumocephalus. Immediate chest drainage might be the best way to stop the migration of air; however, care should be taken to not worsen cerebrospinal fluid leakage.

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.

Osteoblastoma of the frontal sinus: A rare case presenting with seizures and pneumocephalus.

Key Clinical Message: Osteoblastoma of the frontal sinus, although rare, can manifest with seizures and pneumocephalus, underscoring the importance of thorough evaluation and complete surgical excision to prevent serious complications and ensure optimal patient outcomes. Abstract: Osteoblastoma is an infrequent bone tumor, with origins typically in the vertebrae and long bones. While craniofacial involvement is rare, it may occur in regions such as the paranasal sinuses. We present a case of osteoblastoma located in the frontal sinus, an exceptionally uncommon site, resulting in seizures secondary to pneumocephalus. A 21-year-old male presented with a generalized tonic-clonic seizure and postictal confusion. Imaging studies revealed a well-defined lesion in the left frontal sinus causing cortical breach, destruction of the posterior wall, and pneumocephalus. A total surgical excision was performed through bifrontal craniotomy. Histopathological analysis confirmed the diagnosis of osteoblastoma. Postoperative recovery was uneventful, with a follow-up CT scan showing complete lesion excision. Osteoblastomas, especially in the cranial sinuses, are rare entities that may present asymptomatically but can lead to severe complications. The risk of recurrence underscores the importance of complete surgical resection for optimal patient outcomes.

Incidence of and risk factors for chronic subdural hematoma after endoscopic endonasal surgery: quantitative analysis of pneumocephalus.

OBJECTIVE: Chronic subdural hematoma (CSDH) is known to occur after endoscopic endonasal surgery (EES); however, the detailed clinical picture remains unclear. In this study, the authors aimed to examine the incidence of and risk factors for post-EES CSDH, with a focus on the quantitative evaluation of postoperative pneumocephalus. METHODS: The authors retrospectively collected data on consecutive patients who, between November 2016 and December 2022, had undergone EES during which intraoperative cerebrospinal fluid (CSF) leakage occurred. Using CT images obtained immediately after surgery (CT0), the authors measured the extent of pneumocephalus in detail. The locations of pneumocephalus were divided into two groups: remote and local. Remote pneumocephalus was further subdivided into convexity and ventricular. The incidence of post-EES CSDH was calculated, and its risk factors were analyzed. RESULTS: Among the 159 EES patients included in the study, Esposito grade 1, 2, and 3 intraoperative CSF leakage was confirmed in 22 (14%), 27 (17%), and 110 (69%) patients, respectively. CSDH occurred in 6 patients (3.8%). One patient (0.6%) required unilateral burr hole surgery, whereas the hematomas spontaneously disappeared in the others. All CSDHs occurred in patients with Esposito grade 3 CSF leakage and convexity pneumocephalus on CT0. In the multivariate analysis of 149 sides with convexity pneumocephalus on CT0, the product of the diameter and the thickness of convexity pneumocephalus on CT0 was significantly associated with subsequent CSDH (OR 1.21, 95% CI 1.06-1.38, p = 0.004). Using a cutoff value of 10 cm2, CSDH development could be predicted with a sensitivity of 0.82 and specificity of 0.74. CONCLUSIONS: The incidence of post-EES CSDH is acceptably low, and surgery is rarely required. Patients with extensive convexity pneumocephalus on immediate postoperative CT are prone to develop CSDH and thus should be carefully monitored.

Underwater versus Closed Drainage System for Surgical Treatment of Chronic Subdural Hematoma.

OBJECTIVES: Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We hypothesized that effective and timely drainage of subdural space may improve clinical and radiological outcomes. This study was conducted to compare the effectiveness of standard closed drainage and underwater drainage. METHODS: Medical data of 300 surgically treated chronic subdural hematoma CDH patients were retrospectively collected and analyzed. The patients were divided into two 2 groups: Group I with underwater drainage, and Group II with closed drainage. Groups were compared in terms of gender, age, complication rates, recurrence rates, seizure rates, and length of hospital stay. RESULTS: Underwater drainage was found superior to closed system by all clinical and radiographic parameters. The recurrence rate was significantly lower in Group I (2%) compared to with Group II (10%). Subdural empyema was observed in 10 patients in Group II and none in Group I. The seizure rate was higher in Group II (18%) compared to with Group I (5%). Postoperative pneumocephalus rates was were 20% in Group I and 54% in Group II. The length of hospital stay was 6±2.6 days in Group I and 8.9±6.1 days in Group II. The length of intensive care unit (ICU) stay was 0.6±1.12 days in Group I and 2.7±5 days in Group II. A minority (5%) of the patients in Group II required reoperation due to recurrence. CONCLUSIONS: The use of underwater system significantly the reduces the rates of pneumocephalus, seizures, infection, and recurrence. Additional benefits are shorter intensive care unit ICU and total hospital stays.

Management of frontoethmoidal osteoma causing pneumocephalus and cerebrospinal fluid leakage with minimally invasive techniques: illustrative cases.

BACKGROUND: Osteoid osteoma is a common benign bone tumor frequently seen in the frontoethmoid region. However, involvement of the skull base is rare, with few cases previously reported. OBSERVATIONS: The authors report two cases of spontaneous, symptomatic frontoethmoidal osteoma: one presented with neurological deficit secondary to tension pneumocephalus and the other with cerebrospinal fluid leakage. The first case was managed with a transfrontal sinus craniotomy and pneumocephalus decompression with osteoma resection and skull base reconstruction. The second case was managed with a uninaral endoscopic endonasal approach to the anterior skull base with osteoma resection and reconstruction. LESSONS: Given the paucity of cases with associated tension pneumocephalus described in the literature, it was relevant to describe the authors' experience with surgical decision-making and the expected outcomes among patients with this pathology when using minimally invasive techniques.

Minimizing pneumocephalus during deep brain stimulation surgery.

BACKGROUND: Deep brain stimulation (DBS) surgery is an effective treatment for movement disorders. Introduction of intracranial air following dura opening in DBS surgery can result in targeting inaccuracy and suboptimal outcomes. We develop and evaluate a simple method to minimize pneumocephalus during DBS surgery. METHODS: A retrospective analysis of prospectively collected data was performed on patients undergoing DBS surgery at our institution from 2014 to 2022. A total of 172 leads placed in 89 patients undergoing awake or asleep DBS surgery were analyzed. Pneumocephalus volume was compared between leads placed with PMT and leads placed with standard dural opening. (112 PMT vs. 60 OPEN). Immediate post-operative high-resolution CT scans were obtained for all leads placed, from which pneumocephalus volume was determined through a semi-automated protocol with ITK-SNAP software. Awake surgery was conducted with the head positioned at 15-30°, asleep surgery was conducted at 0°. RESULTS: PMT reduced pneumocephalus from 11.2 cm3±9.2 to 0.8 cm3±1.8 (P<0.0001) in the first hemisphere and from 7.6 cm3 ± 8.4 to 0.43 cm3 ± 0.9 (P<0.0001) in the second hemisphere. No differences in adverse events were noted between PMT and control cases. Lower rates of post-operative headache were observed in PMT group. CONCLUSION: We present and validate a simple yet efficacious technique to reduce pneumocephalus during DBS surgery.

Traumatic tension pneumocephalus: a case report and perspective from Indonesia.

Traumatic tension pneumocephalus is a rare and life-threatening complication of traumatic brain injury necessitating prompt diagnosis and neurosurgical treatment. Nevertheless, various possibilities for impedance in timely management, including patient-related barriers are commonly experienced in low-and middle-income countries setting. Here we presented a delay of management in traumatic tension pneumocephalus case due to initial refusal for emergency surgery. A 59-year-old male presented to the emergency department following a motorcycle accident fully alert with no neurological deficit. He acknowledged clear nasal discharge within 1 h after the initial trauma, but no rhinorrhea or otorrhea was present during physical examination. Head CT revealed extensive pneumocephalus with "Mount Fuji sign," anterior skull base fracture, and frontal sinus fracture. The patient initially refused immediate surgical intervention due to excellent clinical condition and financial scare. Acute decrease of consciousness occurred 40 h post-trauma: GCS of 6 with slight dilatation of both pupils (4 mm) and sluggish pupillary reflex. Emergency bifrontal craniotomy, subdural air drainage, and dura mater tear repair were performed afterwards. Postoperative care was uneventful, with rapid improvement of consciousness and follow-up head CT showing minimal subdural fluid collection and absence of remaining pneumocephalus. The patient was discharged from the hospital after 7 days with GCS of 15 and GOS of 5, proving the importance of overcoming barriers for delay in delivering neurotrauma care in low-and middle-income countries.

Simultaneous gas embolism and pneumocephalus after paravertebral irrigation with hydrogen peroxide: A rare case report.

INTRODUCTION: Gas embolism is a rare but fatal clinical emergency. Hydrogen peroxide (H2O2) can cause gas embolism when improperly used in closed cavities or for deep and large wound irrigation. PRESENTATION OF CASE: A 31-year-old woman was diagnosed with lumbar-3 tuberculosis and paravertebral abscess and underwent emergency spinal surgery in a prone position. After removing the tuberculous pus, 200 mL of H2O2 (3 % v/w) was used to repeatedly irrigate the abscess cavity. Immediately after irrigation, the patient suffered cardiac arrest. During cardiopulmonary resuscitation, transesophageal echocardiography revealed that the right cardiac cavity was filled with a diffuse "Snowflake-Like" gas embolus, and cranial computed tomography showed a multi-point pneumocephalus in the frontal lobes. The patient eventually suffered brain death despite the return of spontaneous circulation after active resuscitation. DISCUSSION: H2O2 can quickly release abundant oxygen and water upon contact with catalase. Oxygen bubbles enter the vascular lumen and cause mechanical obstruction of the right cardiac circulation. In addition, H2O2 and oxygen bubbles may migrate upwards and enter the intracranial tissue through the epidural space or subdural space, resulting in intracranial pneumatosis. Diagnosis and treatment of gas embolism are extremely difficult. Some suggestions are that H2O2 should not be used in closed cavities or on deep and large wounds due to the potential risk of fatal gas embolism. CONCLUSION: The fatal complications of gas embolism and pneumocephalus rarely occur simultaneously in one patient, and we aim to highlight this potential risk of intraoperative H2O2 use in spinal surgery.

Pneumocephalus and empyema in the subarachnoid space: An unusual imaging feature secondary to spinal-epidural anesthesia.

Pneumocephalus and empyema in the subarachnoid space secondary to spinal-epidural anesthesia are very rare and have not previously been reported, to our knowledge. Here, we describe the imaging features of an older woman presenting with pneumocephalus plus subarachnoid and intraventricular empyema due to Staphylococcus epidermidis infection after spinal-epidural anesthesia, with the aim of raising awareness regarding this serious complication.

Klebsiella pneumoniae invasive syndrome with pneumocephalus and extensive cerebral infarction: Case report.

A 54-year-old female with diabetes was admitted with fever and altered consciousness. Laboratory tests revealed venous blood glucose level of 43.79 mmol/L. Computed tomography (CT) scans of the head, chest, and abdomen showed a right-sided pneumothorax, consolidation, and atelectasis in the right lung; a large heterogeneous density lesion with fluid and gas-fluid levels in the liver; and scattered gas shadows in both kidneys, respectively. Blood and puncture fluid cultures indicated infection with Klebsiella pneumoniae. Based on the susceptibility profiles of the isolates, imipenem was administered intravenously to treat the infection. On the third day of hospitalization, the patient's condition worsened, with head CT showing an extensive cerebral infarction and multiple gas accumulations in the right cerebral hemisphere, as well as a large-area cerebral infarction in the left parietal and occipital lobes. Ultimately, the patient died of multiple organ dysfunction on the fourth day after initial presentation. Although the Klebsiella pneumoniae isolates from the patient showed sensitivity to imipenem, this antibiotic shows poor entry into the central nervous system. The death of the patient indicates that the selection of antibiotics that can cross the blood-brain barrier may be crucial in the outcome of this type of case. Therefore, antibiotics that can penetrate the blood-brain barrier should be selected as soon as possible, and empirical treatment must be initiated immediately after clinical suspicion of invasive Klebsiella pneumoniae, even if the diagnosis has not been determined.

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.