Symptomatic Pneumocephalus After Trans-sphenoidal Surgery

Abstract

A 43-year-old woman underwent endoscopic transsphenoidal resection of a 34-mm nonfunctioning pituitary macroadenoma with optic chiasmal compression. Cerebrospinal fluid (CSF) leak was noted and repaired with gelfoam and a duraseal (hydrogel sealant) buttressed with Nasopore. Day 4 postsurgery, she had ongoing postnasal drip, and she rapidly deteriorated with headaches, drowsiness, vomiting, and urinary incontinence. She was receiving adequate hydrocortisone replacement, serum sodium levels were normal, and CSF cultures excluded infection. Brain computed tomography (CT) showed significant pneumocephalus with mass effect (Figure 1). Figure 2 shows air in the prefrontal region (Mount Fuji sign) and cisterns (air bubble sign) on coronal sections. Initial management comprised high-flow oxygen therapy and a lumbar drain with controlled CSF release. Despite treatment, she developed Cushing’s reflex, with systemic hypertension and bradycardia, suggesting intracranial hypertension. Serial imaging demonstrated progressive tension pneumocephalus, and the lumbar drain was clamped. Repeat surgery confirmed a moderate CSF leak (Daniel Kelly system grade 2) (1), which was repaired using a fat graft. Neurological status markedly improved, and there was complete clinical recovery. Symptomatic tension pneumocephalus after transsphenoidal pituitary surgery is a rare but serious complication, necessitating rapid recognition (2, 3). Conservative treatment with high-flow oxygen increases the rate of resorption of pneumocephalus (4). Early surgical repair of the CSF leak should be considered in moderate to severe cases (5). Lumbar drainage in the presence of intraoperative CSF leak and significant pneumocephalus may exacerbate the pneumocephalus by drawing in air from the nasal passages.