Traumatic Pneumocephalus

Abstract

Prior to the advent of radiologic diagnosis, only one case of traumatic pneumocephalus had been reported. Extracranial pneumatocele, characterized by the dissection of air through the subaponeurotic tissues of the scalp, has long been recognized, but its intracranial counterpart, following fracture of the paranasal sinuses or mastoids, was not so accessible to the usual methods of diagnosis. Since the report of Luckett in 1913, many cases of pneumocephalus have been recorded, and major contributions such as those of Dandy and Lewis have appeared. The following case presents evidence of the immediate development of pneumocephalus following skull fracture, a somewhat unusual finding. A well developed white male was attacked by thieves as he stopped to change a tire early in the morning of April 10, 1948. He evidently was struck about the head and face by some blunt object. He was found unconscious on the street shortly after the beating and was brought immediately to Wesley Memorial Hospital. Films of the skull and facial bones taken probably four or five hours after injury were not entirely satisfactory because of the patient's disoriented condition. They revealed, however, various linear fractures in the vault, chiefly on the left, with multiple fracture lines entering the base of the skull in the region of the sphenoid yoke and the cribriform plate. Fracture of the lateral wall of the right maxillary sinus, with dense clouding of this sinus, was also observed. A large amount of air was seen within the subarachnoid space, both in the basal cisterns and surrounding the cerebral convexities. The lateral ventricles were well delineated by air (Fig. 1). Air was also present in the subdural space about the falx (Fig. 2). Physical examination on entry to the hospital showed edema and ecchymosis of the periorbital tissues. The left pupil was larger than the right, and there was no evidence of light perception by the left eye. A large hematoma was present over the left temporal bone, and there were a few small lacerations, the largest involving the left ear. Dry blood was seen in the nasal cavity, but no cerebrospinal fluid rhinorrhea or otorrhea was observed at this time. There were no cranial nerve motor changes, and generally the reflexes were normal; no signs of meningeal irritation were present. Blood pressure was 130/78. Laboratory findings were not significant. By April 11 the patient was fully conscious. He received penicillin and sulfonamides from the time of admission to April 18. Parenteral fluids were discontinued after the first two days, after which time he took nourishment by mouth. The blood pressure ranged from 120 to 140 systolic and from 68 to 90 diastolic. The temperature, which rose to 103° F. on April 12, subsided rapidly and remained under 99.4° to the time of discharge. Ophthalmologic examination on April 14 revealed complete blindness of the left eye, and it was concluded that the left optic nerve had been severed.