Post-traumatic tension pneumocephalus and cystic angiomatosis of the skull: case report

Haythem H Osman,Murtada I Abdellatief,Khalid O Elzein,Tarig A Nafie,Nazik E Abdullah,Ali M Abdelsatir,Emad I Ahmed,Ghada S Alhassan

doi:10.1186/s43163-021-00187-6

Haythem H Osman, Murtada I Abdellatief + Show 6 more

Open Access

https://doi.org/10.1186/s43163-021-00187-6

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Abstract

BackgroundTension pneumocephalus is an increasing air trapped intracranially. Either spontaneous, post-traumatic or iatrogenic in origin. Cystic angiomatosis is a benign vascular hamartoma of the skeleton, when acquired it is either due to trauma or infection. This is the second report in English literature of post-traumatic delayed tension pneumocephalus with the development of cystic angiomatosis of the skull bone.Case presentationA 55-year-old gentlemen, presented with scalp swelling of 6-month duration with history of head trauma 2 years back. The swelling was increasing and associated with progressive walking difficulties and left hearing loss. CT scan and MRI revealed extradural pneumocephalus, parietal and occipital pneumatocele, and multiple lytic bony lesions, left mastoid hyperpneumatization with inner table defect communicating with the extradural space. Diagnosis of delayed extradural tension pneumocephalus was made. Surgical exploration revealed multiple bony defects of parietal, temporal and squamous part of left temporal bones, confirmed extradural pneumocephalus with intact dura. Repair of mastoid defect of (0.5 × 0.5 cm), excision of pneumatocele and removal of lytic bones were performed. Defective bone “cribriform-like” was identified at occipital and parietal regions centrally with a defect of nearly 7 × 7 cm. Future cranioplasty was considered after 6 months. Histology of bony chips and surrounding soft tissues is recognized as cystic angiomatosis.ConclusionsThe present case developed two very rare complications, following trivial head trauma; the first complication was delayed extradural tension pneumocephalus with pneumatocele which presented 2 years after trauma, the origin of air was from a defect of the inner table of the mastoid, the second complication was cystic angiomatosis of the skull bones. Both complications were managed surgically in one operative session as a combined neurosurgery and otolaryngology teams approach.

Highlights

Tension pneumocephalus is an increasing air trapped intracranially
The present case developed two very rare complications, following trivial head trauma; the first complication was delayed extradural tension pneumocephalus with pneumatocele which presented 2 years after trauma, the origin of air was from a defect of the inner table of the mastoid, the second complication was cystic angiomatosis of the skull bones
We report a rare case of head trauma who developed two rare complications: delayed tension pneumocephalus with pneumatocele and cystic angiomatosis

Summary

Conclusions

Air was trapped from the mastoid air cells in the extradural space via a defect in the inner table of the mastoid, in a one-way valve mechanism. Pneumatocele developed in the present case as a result of multiple occipital and parietal bony defects that permit air to escape from extradural space, despite this there was no relief of pneumocephalus as the patient remained symptomatic with walking difficulties indicating that this is a tension type of pneumocephalus. Treatment of skull cystic angiomatosis is usually surgical excision, which is not always easy, e.g., when present over the transverse sinus it is difficult to be excised without significant morbidity [10]. A novel procedure is advented recently with promising results, by Guilherme et al, to treat difficult occipital skull lesions directly overlying the transverse sinus, and the procedure is done by performing a small, partial-thickness craniectomy and alcohol sclerotherapy in a combined neurosurgery-neuroendovascular approach [10]

Background

Findings