Spontaneous Pneumocephalus: A Case Report with a Literature Review.

BACKGROUND: Pneumocephalus is defined as gas in the intracranial space. Common causes include head trauma, surgery, and diagnostic/therapeutic procedures resulting from the direct disruption of the dura. Spontaneous or nontraumatic pneumocephalus is an uncommon condition, often caused by infection, either due to insidious disruption of the dura or gas-forming pathogens. CASE REPORT: Herein, we report a rare case of spontaneous pneumocephalus associated with meningitis in a patient who received conservative treatment without surgical intervention. Blood culture revealed group A streptococcus. The pneumocephalus subsided gradually with antibiotic treatment, and no neurological deficits remained. A follow-up brain computed tomography scan showed the absence of pneumocephalus, but it showed progressive hydrocephalus. The patient was discharged on the 21st day of hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous pneumocephalus associated with meningitis is rare. It should always raise the suspicion of meningitis and prompt suitable treatment. Emergency physicians should always be vigilant for this particular possibility on brain computed tomography.

Post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia: a case report.

BACKGROUND: Pneumocephalus is rare in vaginal deliveries. Pneumocephalus may be asymptomatic or present with signs of increased intracranial pressure. However, parturients who received epidural anesthesia with air in their brains may experience low intracranial pressure headaches after giving birth, causing the diagnosis of pneumocephalus to be delayed. We report a case of a parturient who developed post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia. CASE PRESENTATION: A 24-year-old G1P0 Chinese woman at 38 weeks gestation was in labor and received epidural anesthesia using the loss of resistance to air technique and had a negative prior medical history. She presented with postural headache, neck stiffness and auditory changes 2 h after vaginal delivery. The head non-contrast computed tomography revealed distributed gas density shadows in the brain, indicating pneumocephalus. Her headache was relieved by bed rest, rehydration, analgesia, and oxygen therapy and completely disappeared after 2 weeks of postpartum bed rest. CONCLUSIONS: This is the first report that positional headaches after epidural anesthesia may not indicate low intracranial pressure alone; it may combine with pneumocephalus, particularly when using the loss of resistance to air technique. At this moment, head computed tomography is essential to discover other conditions like pneumocephalus.

Dynamic Lateral Semisitting Position for Supracerebellar Approaches: Technical Note and Case Series.

BACKGROUND: It has always been a matter of debate which position is ideal for the supracerebellar approach. The risk of venous air embolism (VAE) is the major deterrent for surgeons and anesthesiologists, despite the fact that sitting and semisitting positions are commonly used in these operations. OBJECTIVE: To demonstrate a reduction on the risk of VAE and tension pneumocephalus throughout the operation period while taking advantages of the semisitting position. METHODS: In this study, 11 patients with various diagnoses were operated in our department using the supracerebellar approach in the dynamic lateral semisitting position. We used end-tidal carbon dioxide and arterial blood pressure monitoring to detect venous air embolism. RESULTS: None of the patients had clinically significant VAE in this study. No tension pneumocephalus or major complications were observed. All the patients were extubated safely after surgery. CONCLUSION: The ideal position, with which to apply the supracerebellar approach, is still a challenge. In our study, we presented an alternative position that has advantages of the sitting and semisitting positions with a lower risk of venous air embolism.

60-year-old male with rapidly progressive pneumocephalus caused by Clostridium septicum in the setting of an occult colonic adenocarcinoma.

BACKGROUND: Disseminated Clostridium septicum infection is an uncommon complication associated with malignancies, particular colonic adenocarcinoma. The organism appears to preferentially colonize large masses in rare individuals and subsequently seed the blood via mucosal ulceration. This has rarely been reported to lead to central nervous system infection and, in several cases, rapidly progressive pneumocephalus. In the few cases reported, this was a universally fatal condition. The current case adds to the reports of this extremely rare complication and provides a unique and complete clinicopathologic characterization with autopsy examination, microscopy, and molecular testing. CASE PRESENTATION: A 60-year-old man with no known past medical history was discovered having seizure-like activity and stroke-like symptoms. Blood cultures turned positive after six hours. Imaging revealed a large, irregular cecal mass as well as 1.4 cm collection of air in the left parietal lobe that progressed to over 7 cm within 8 h. By the following morning, the patient had lost all neurologic reflexes and died. Post-mortem examination revealed brain tissue with multiple grossly evident cystic spaces and intraparenchymal hemorrhage, while microscopic exam showed diffuse hypoxic-ischemic injury and gram-positive rods. Clostridium septicum was identified on blood cultures and was confirmed in paraffin embedded tissue from the brain by 16 S ribosomal sequencing and from the colon by C. septicum specific PCR. CONCLUSIONS: C. septicum is an anaerobic, gram-positive rod that can become invasive and is strongly associated with gastrointestinal pathology including colonic adenocarcinomas. Central nervous system infection with rapidly progressive pneumocephalus is a rarely reported and universally fatal complication of disseminated C. septicum infection.

Electrode Fixation with Bone Cement or Stimloc® in Deep Brain Stimulation Surgery: A Comparative Study.

AIM: To examine the postoperative outcomes of electrode fixation using bone cement and Stimloc® in patients with Parkinson?s disease (PD) who underwent subthalamic nucleus (STN) deep brain stimulation (DBS). MATERIAL AND METHODS: Between 2016 and 2018, permanent electrode fixation was performed in 30 patients with PD, of which 15 received bone cement and the remaining 15 received Stimloc®. Data regarding preoperative Unified Parkinson?s Disease Rating Scale (UPDRS) III scores, levodopa equivalent daily dose (LEDD) values, surgery duration, and the fixation technique used were recorded. Brain computed tomography was performed for early postoperative evaluation of pneumocephalus and possible hematoma as well as for the determination of migration 1 year postoperatively. UPDRS III scores and LEDD values were re-evaluated 1 year postoperatively; surgery duration, clinical effectiveness, and complication rates were compared between the two fixation techniques. RESULTS: A statistically significant difference in application time was observed between the two techniques (bone cement: 21 min, Stimloc®: 6 min). After 1 year from surgery, 0.92- and 0.88-mm migrations were observed in the bone cement and Stimloc® groups, respectively. A significant correlation between migration and the pneumocephalus volume was observed in both groups. No differences were observed between the groups regarding infection, migration, pneumocephalus volume, wound erosion, and clinical outcomes. CONCLUSION: Stimloc® is preferred over bone cement for electrode fixation in DBS surgeries as it is associated with shorter application duration; this increases patient comfort and tolerance during awake surgery. Clinical efficacy and complication rates associated with both techniques are similar.

Pulsatile tinnitus caused by pneumocephalus after Janneta surgery.

Pulsatile tinnitus of nonvascular origin is rare. We herein present a case of pulsatile tinnitus complicated with Jannetta surgery due to a communication created between the drilled mastoid cells and epidural space. She was successfully cured by otological surgery where the mastoid tip was packed with bone cement. A 68-year-old woman was referred to the previous hospital with complaints of right autophony, aural fullness, hyperacusis to her footsteps, and pulsatile tinnitus for the past three years. She had received Jannetta surgery for right hemifacial spasm seven years before. The computed tomography (CT) of the right temporal bone showed bony dehiscence between the mastoid cells and posterior cranial fossa. She underwent otological surgery to obliterate the tip of the mastoid cavity with artificial bone cement (BIOPEXⓇ) under general anesthesia. Her annoying aural symptoms were immediately abolished and she has been free from symptoms at ten months after surgery. It is critical to ensure the closure of any communication created between the middle ear and epidural space during surgeries in order to prevent the occurrence of pulsatile tinnitus.

Acute hydrocephalus secondary to traumatic perimesencephalic pneumocephalus: A case report.

INTRODUCTION: Acute hydrocephalus is a common complication of spontaneous or traumatic intracranial bleeding with extensive subarachnoid hemorrhage (SAH) or ventricular extension. However, it has never been reported to be secondary to pneumocephalus. PATIENT CONCERNS: A 32-year-old man was admitted following a motorcycle accident. Head computed tomography (CT) performed right after the accident revealed a skull base fracture and mild perimesencephalic SAH. Three days later, repeated CT revealed delayed perimesencephalic pneumocephalus and an evident enlargement of the ventricular system. DIAGNOSIS: The patient was diagnosed with acute obstructive hydrocephalus, which was secondary to pneumocephalus and traumatic SAH. INTERVENTIONS: The patient was treated with temporary external ventricular drainage (EVD). OUTCOMES: The patient experienced an unremarkable recovery process. At follow-up 3 months later, he showed no recurrence of the hydrocephalus and the score of Glasgow Outcome Scale was 5. CONCLUSION: Transient mechanical obstruction of CSF circulation and disturbance of CSF physiology might conjointly lead to the acute obstructive hydrocephalus.

Speech bubble: dysphasia secondary to spontaneous intraparenchymal pneumocephalus.

Spontaneous pneumocephalus is exceptionally rare, with few published cases in the literature. We describe a patient presenting with dysphasia, right facial weakness, headache and confusion who was subsequently found to have pneumocephalus due to an encephalocoele herniating into a tegmen tympani defect.

Frontotemporal dementia: an unusual cause.

Intracerebral pneumocephalus is commonly associated with head and facial trauma, ear infection, tumors and surgical interventions. Osteomas are relatively common, benign tumors that occur mainly in the paranasal sinuses, the frontal sinus in particular. Pneumocephalus has been commonly reported with frontal osteoma but isolated presentation as frontotemporal dementia is uncommon. Patient was admitted with complaints of change of behavior and forgetfulness for the last one year. He had progressively become more apathetic and presented with behavioral abnormalities. General physical examinations were within normal limits including the motor and sensory system although neuropsychiatry assessments were below the average level, with features of dementia. Further, MRI brain revealed pneumocephalus in bilateral frontal lobe. CT cisternography revealed a well defined lobulated densely sclerotic lesion of approximate size 20 × 17 × 27mm transverse and cranio-caudal axis respectively arising from right ethmoid sinus. Clinically, the association of pneumocephalus and isolated presentation as frontotemporal dementia has not been described to the best of our knowledge. A single case has been described with ethmoid osteoma. Radiological features were suggestive of osteoid osteoma. The uniqueness of the case is the development of dementia with frontotemporal involvement and resemblance with Frontotemporal Dementia. This is the only case with dementia and pneumocephalus (secondary to osteoid osteoma) to best of our knowledge.

A rare case of concomitant pneumocephalus and pneumorachis after lumbar spine surgery with late presenting dural leak.

Introduction: We report a case of pneumocephalus and pneumorachis i.e., air in the cranial cavity and the spinal canal, which are rarely associated with a primary spinal cause. Their concomitant occurrence and association with a late presenting dural leak are also uncommon. Case presentation: A 70-year-old man presented 1 month after decompressive surgery for lumbar canal stenosis with leakage of cerebrospinal fluid (CSF) from the wound site and severe headache. There were no signs of surgical site infection or meningitis. There was no intraoperative or immediate postoperative evidence of dural tear. He was neurologically intact. On detailed work-up, he was found to have air collections in the subarachnoid and intraventricular spaces in the brain and intraspinal air in both the cervical and the lumbar regions. He showed gradual resolution of these findings radiologically and symptomatic improvement through conservative management with analgesics, empirical antibiotics, high flow oxygen, and maintenance of hydration within 1 month. Discussion: Pneumocephalus and pneumorachis are commonly seen after trauma. Spine surgery is a rare cause. They may present with symptoms similar to meningitis and may be erroneously diagnosed and treated. No standard treatment guidelines exist in the literature. Most cases have been managed conservatively. Early detection may allow noninvasive management leading to complete resolution.

Pneumocephalus with Conscious Disturbance After Full Endoscopic Lumbar Diskectomy.

BACKGROUND: Pneumocephalus is a rare complication after an elective lumbar spine surgery. Full endoscopic lumbar diskectomy (FELD) is an evolving minimally invasive surgical procedure gaining its popularity in the past decade. Although seizure was recognized as a possible complication, organic injury to the central nervous system such as pneumocephalus has not yet been reported after FELD. CASE DESCRIPTION: A 63-year-old man with L3-4 intervertebral disk herniation received FELD via the transforaminal approach under general anesthesia. A small dural tear about 2 mm was encountered. After the operation, the patient was unable to recover from anesthesia and failed to be extubated due to tachypnea and generalized tonic-clonic seizures. Emergent brain computed tomography (CT) revealed pneumocephalus in the subdural and subarachnoid space. Pure oxygen was given, and hyperbaric oxygen therapy (HBO2) was arranged immediately. Fortunately, he started to regain his consciousness 8 hours after the operation and had full recovery of consciousness on the next day. Follow-up brain CT showed nearly complete resolution of the pneumocephalus. He had no neurologic deficits at final follow-up. CONCLUSIONS: This case report highlights the risk of pneumocephalus with conscious disturbance when a dural tear occurs during FELD under general anesthesia. FELD is safer when performed under local anesthesia because the patient is awake to report his discomfort and thus possible to prevent serious neurologic sequels. An emergent brain CT is critical to obtain a prompt diagnosis and HBO2 is probably helpful for resolving the mass effect caused by the pneumocephalus.

Risk Factors Predicting Recurrence of Bilateral Chronic Subdural Hematomas after Initial Bilateral Evacuation.

BACKGROUND: Most patients with bilateral chronic subdural hematomas (bCSDH) undergo initial bilateral evacuation. Risk factors associated with the recurrence of bCSDH after initial bilateral evacuation have not been published to date. In this study, we aimed to identify risk factors related to recurrence of bCSDH after initial bilateral evacuation, and to develop a prognostic grading system for clinical reference. METHODS: This study included 102 patients with bCSDH who underwent initial bilateral evacuation. Predictors of recurrence were identified via univariate analysis and multivariate logistic regression analysis. A prognostic grading system was created based on the independent predictors combined with a cutoff value. All cases were scored according to the prognostic grading system, and the recurrence rates of the different scores were reanalyzed. RESULTS: Anticoagulant use (odds ratio [OR], 84.266; 95% confidence interval [CI], 13.113-541.522; P < 0.001), severe brain atrophy (OR, 11.551; 95% CI, 2.558-52.163; P = 0.001), and postoperative pneumocephalus volume (PostPV) (OR, 0.978; 95% CI, 0.957-1.000; P = 0.049) were independent risk factors for the recurrence of bCSDH after initial bilateral evacuation. The cutoff value of PostPV was >20.9484 cm3. A prognostic grading system was then developed, and the recurrence rates based on score were determined. Rates were 2.8% for a score of 0-1, 28.1% for a score of 2-3, and 100% for a score of 4-5, showing a significant increase in risk with increasing score (P < 0.001). CONCLUSIONS: Anticoagulant use, severe brain atrophy, and PostPV were identified as independent risk factors for recurrence of bCSDH after initial bilateral evacuation. The prognostic grading system for recurrence of bCSDH after initial bilateral evacuation is reliable and applicable for clinical reference.

Intraoperative High Impedance Levels During Placement of Deep Brain Stimulating Electrode.

BACKGROUND AND IMPORTANCE: Deep brain stimulation (DBS) is a well-established treatment for medically refractory Parkinson's disease (PD), essential tremor (ET), and dystonia. The field of DBS is expanding and techniques are under investigation for the treatment of several neurological disorders. A critical component of the success of these procedures depends significantly on the reliability and durability of devices implanted. Immediate feedback during surgery often gives the surgeon and patient a sense of confidence of long term success. When impedances are found to be elevated during the implantation of the DBS leads, appropriate trouble shooting measures are critical. CLINICAL PRESENTATION: We present a 73-yr-old male undergoing awake subthalamic DBS with microelectrode recordings for severe PD. Once the optimal trajectory and depth were ascertained, the permanent DBS electrode was placed. High impedances were recorded. Troubleshooting procedures were performed and were all negative as to the cause of the values. Correct impedance levels of the DBS electrode was confirmed with extracranial testing, but continued high values were found again with intracranial positioning of the electrode. A postoperative computerized tomography (CT) scan confirmed intracranial air surrounding all of the contacts. The patient went on to outpatient programming with excellent clinical results. CONCLUSION: The presence of pneumocephalus surrounding the DBS lead contacts at the target nucleus may have accounted for the intraoperative impedance findings. When all troubleshooting checks have not identified an explanation for the high impedances, intraoperative imaging may demonstrate pneumocephalus around the lead contacts, which should resolve and impedances return to normal values.

[Brain death due to pneumocephalus and dural fistula in the post-operative period for a herniated lumbar disc]. / Muerte encefalica por neumoencefalo y fistula dural en el postoperatorio de hernia discal lumbar.

TITLE: Muerte encefalica por neumoencefalo y fistula dural en el postoperatorio de hernia discal lumbar.

Muerte encefálica por neumoencéfalo y fístula dural en el postoperatorio de hernia discal lumbar / Brain death due to pneumocephalus and dural fistula in the post-operative period for a herniated lumbar disc

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[Intraoperative intracerebral tension pneumocephalus secondary to hydrogen peroxide as a hemostatic agent]. / Neumoencefalo a tension intraoperatorio secundario al uso de peroxido de hidrogeno como agente hemostatico.

TITLE: Neumoencefalo a tension intraoperatorio secundario al uso de peroxido de hidrogeno como agente hemostatico.

Canalis basalis medianus with cerebrospinal fluid leak: rare presentation and literature review.

Canalis Basalis Medianus is a rare congenital normal anatomically variant of the clivus .We report a very rare case of cerebrospinal fluid leak from a canalis basilaris medianus in a 22-year-old male, who presented to our hospital with frontal headache and running nose two weeks after an elective septoplasty.