Severe Pneumocephalus Research Articles

Dynamics and diagnosis of severe pneumocephalus of unknown etiology in dog

Modern veterinary medicine and its subdivision – veterinary neurology, are constantly evolving. New diagnostic methods are emerging every day, and the list of new, previously unexplored animal diseases is expanding. Much information about the pathogenesis and etiology of diseases is borrowed from human medicine, which is a big problem, because human physiology is different from animals and, as a consequence, the dynamics of the disease are also different. That is why the continuous improvement of veterinary therapy and diagnosis of diseases is relevant and necessary. One of the rare and severe pathologies is pneumocephalus. It is reported that this is a condition in which there is a gradual accumulation of air in the cranial cavity or ventricles of the brain, creating a life-threatening condition. It is considered that pneumocephalus can occur spontaneously but, in most cases, is diagnosed after trauma or surgery with impaired integrity of the skull bones and meninges. This article describes a case of pneumocephalus of unknown etiology in a young dog who suffered a head injury while playing with the owner. During the neurological examination of the animal conducted immediately after the incident was diagnosed with severe central nervous system lesions (sopor, opisthotonus, tetraparesis); magnetic resonance imaging revealed significant brain damage with pronounced ventricular dilatation and the formation of a cavity filled with air. Re-diagnosis after 14 days showed progression of pneumocephalus with gas accumulation in the brain cavities. The contents of the ventricles have a division into liquid (cerebrospinal fluid), and air, progressive inflammatory processes in the brain's parenchyma were not observed; a fistula or canal connecting the cranial cavity and the external environment was not detected. Symptomatic and supportive therapy, carried out during the entire period of the dog's stay in the veterinary clinic, did not have positive results. The animal was euthanized according to medical indications and the owner's wishes.

New Tools and Techniques to Prevent CSF Leak in Cranial and Spinal Surgery.

Cerebro-spinal fluid (CSF) leak in cranial and spinal surgery seriously threatens the clinical prognosis of surgical cases exposing the patients to higher risk of infection, prolonged hospital stay, and need of reoperation. Ultimately, this cascade of events may lead to life-threatening complications, as in cases of meningitis/encephalitis, spondylodiscitis, subdural hematomas, and severe pneumocephalus. Moreover, CSF leak causes a consistent rise in healthcare-related costs which are nearly doubled in CSF leak cases after craniotomy or in spinal surgery. The risk of CSF leak tends to be higher in patients undergoing transnasal endoscopic surgery, posterior fossa craniotomies, and spinal surgery, while being considered a quite rare finding in supratentorial brain surgery. Here we analyzed the different implications of this issue focusing on the usefulness of new technologies and surgical strategies to prevent it. CSF leak rate may vary from 4% in transsphenoidal procedures to 32% in posterior fossa craniotomies. In spinal surgery, CSF leak may be a consequence of elective intradural surgery, accounting for 18% of the procedures, or being a result of incidental durotomies, ranging from 1 to 17% in different surgical series. Dural closure's reinforcement using different new dural sealants plays an important role in preventing these events. Moreover, the use of neuronavigation systems in skull base and posterior fossa surgery can help to minimize the size of approach and reduce the incidence of CSF leak. New minimally invasive spinal approaches, such as minimally invasive decompression for spinal degenerative disorders or performing selective laminotomies over laminectomies for intradural spinal pathology are very useful techniques to prevent CSF leak in this kind of surgery. In conclusion, although CSF leak remains a risky complication in neurosurgery, its prevention and treatment significantly benefited from advances in biomaterials and surgical technique.

Symptomatic Pneumocephalus After Spinal Intradural-Extramedullary Tumor Surgery

Durotomy is a necessary procedure for resection of spinal intradural-extramedullary (IDEM) tumor. The purpose of this study was to investigate the prevalence and clinical implications of pneumocephalus after spinal IDEM tumor surgery and also the association between pneumocephalus and postoperative headache. This prospective study was conducted in a cohort of 20 patients who were diagnosed with a spinal IDEM tumor and underwent surgical resection. The mean patient age was 53.6 years (range, 29-75 years). Histological findings revealed schwannoma in 16 cases (80.0%) and meningioma in 4 cases (20.0%). Brain computed tomography scan was performed immediately after surgery. The prevalence and severity were analyzed based on the classification into 4 groups according to the extension of pneumocephalus: absence, mild, moderate, and severe. A visual analog scale (VAS; range 0-10) for headache was reported daily for the first postoperative week. Headache-related pneumocephalus was defined as a VAS score of ≥5 points at least once in that 1-week period. The prevalence of pneumocephalus was 90.0% (18 patients). Five patients (25.0%) had severe pneumocephalus extending to the extra-axial space. Seven of the 20 patients (38.9%) complained of significant headache. Five of these patients had severe pneumocephalus, 1 patient had moderate pneumocephalus, and 1 patient had moderate pneumocephalus. A statistically significant association was observed between the severity of pneumocephalus and headache (P= 0.001). Pneumocephalus is a common complication after spinal IDEM tumor surgery. This report is the first study to investigate the prevalence of pneumocephalus and analyze its association with headache after spine surgery. The severity of pneumocephalus was significantly related to postoperative headache.

Skull base osteosarcoma presenting with cerebrospinal fluid leakage after CyberKnife® treatment: a case report

IntroductionCyberKnife® radiation is an effective treatment for unresectable skull base tumors because it can deliver a highly conformational dose distribution to the complex shapes of tumor extensions. There have been few reports of severe complications with this treatment. This is the first published case report to our knowledge of cerebrospinal fluid leakage induced by CyberKnife® radiotherapy.Case presentationA skull base tumor was identified on magnetic resonance imaging in a 78-year-old Asian woman with a headache in her forehead. An endoscopic transnasal tumor resection was performed; however, the tumor, invading into the cavernous sinuses and optic canal, was not completely removed. During the subtotal resection of the tumor, no cerebrospinal fluid leakage was observed. Osteosarcoma was histologically diagnosed, and CyberKnife® radiation was performed to the residual tumor considering the aggressive feature of the tumor with a molecular immunology Borstel-1 index of 15%. Five months after the treatment, magnetic resonance imaging showed definite tumor shrinkage, and the patient had been living her daily life without any troubles. After another month, the patient was transferred to our clinic because of coma with high fever, and computed tomography demonstrated severe pneumocephalus. Rhinorrhea was definitely identified on admission; therefore, emergency repair of the cerebrospinal fluid leakage was performed using an endoscope. Dural defects at the bottom of the sella turcica were identified under careful endoscopic observation and fat tissue was patched to the dural defects. Follow-up computed tomography proved complete disappearance of air from the cisterns 2 weeks after the surgery, and the patient was discharged from our hospital without any neurological deficits.ConclusionCyberKnife® radiation is one of the effective treatments for skull base tumors; however, the risk of cerebrospinal fluid leakage should be considered when tumor invasion to the dura mater is suspected. Emergency surgical treatment is required when cerebrospinal fluid leakage is induced by the radiotherapy because the leakage is not expected to be healed by palliative treatments.

Suggesting Caution for Pneumocephalus and Anterior Skull Base Fracture in the Setting of Epistaxis after Head Injury

Pneumocephalus is common after neurosurgical and sinus procedures, but also after traumatic base of skull fractures. An elderly woman presented after a fall with epistaxis, confusion, and progressive conscious decline. CT showed a right-sided cribriform plate fracture and severe pneumocephalus involving the extradural, subdural, intraventricular, and posterior fossa compartments. It was postulated the “epistaxis” was a blood-stained CSF leak, which allowed the intracranial pressure to drop, encouraging air to enter the subarachnoid/subdural space by means of a dehiscence in the skull base, creating a CSF fistula. We hereby describe a distinct radiological entity, the “twin peaks” sign, which should not be confused with the mount Fuji sign. In the latter, the frontal lobes are collapsed by pneumocephalus in the convexity of each hemisphere. The significance of the twin peaks sign is twofold: (1) The frontal lobes collapse, like in the Mount Fuji sign, but there is, in addition, air entrapment in the interhemispheric space, which may lead to compression from the center outward as well as to compression from the convexity inward. (2) The separation of the frontal lobes beyond the point of their tips, causing these prominent peaks, is a sign of increased tension. This suggests the air pressure is at least greater than that of the surface tension of cerebrospinal fluid between the frontal lobes. It also suggests the bridging veins are not intact. Epistaxis in the setting of head injury, whether severe or mild and repetitive, should alert to the possibility of CSF leak and skull base fracture. Progressive neurological decline should prompt investigations to exclude tension pneumocephalus. The twin peaks sign should lead to immediate referral to neurosurgery.

Pneumocephalus with BiPAP use after transsphenoidal surgery

While the benefits of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) for patients with obstructive sleep apnea are well described, reports in the literature of complications from its use are rare. A patient who received postoperative BiPAP after undergoing transsphenoidal craniopharyngioma resection developed severe pneumocephalus and unplanned intensive care unit admission. Although the pneumocephalus resolved with conservative management over two weeks, we propose caution in the use of CPAP postoperatively in patients undergoing procedures of the head and neck.

Severe pneumocephalus after penetrating injury to the lumbar spine

Introduction: Pneumocephalus is air or gas located in the intracranial cavity. Head trauma is the most common cause of pneumocephalus, with the majority of cases resulting from sinus and basilar skull fractures. A small number of case reports have been published describing pneumocephalus after cervical and thoracic penetrating injuries. To our knowledge, we report the first case of severe pneumocephalus in a patient with multiple penetrating stab wounds to the lumbar spine. Case Report: A healthy 21­year­old male presented to the trauma service with multiple stab wounds to the chest and lumbar spine after being assaulted. Computed tomography scans demonstrated severe pneumocephalus and pneumorrhachis. The patient had neurological deterioration and repeat head scans revealed worsening pneumocephalus. Myelography revealed a cerebrospinal fluid leak and thus warranted neurosurgical intervention to repair a dural tear. The patient made a full recovery without any neurological sequelae. Conclusion: Pneumocephalus caused by penetrating spinal trauma is exceedingly rare, especially to the lumbar spine and an extensive review revealed no cases in the literature. Our patient’s mechanism of trauma along with his clinical symptoms and radiographic images led to his timely diagnosis, avoidance of tension pneumocephalus and allowed for the most appropriate interventions for a full neurological recovery. The common etiologies, symptoms, diagnostic methods and treatment options relevant to this case will be reviewed.

Severe traumatic pneumocephalus in association with epistaxis: the "twin peaks" sign

An 88-year-old woman suffered recurrent falls. After one such fall, she presented with epistaxis, confusion, and progressive conscious decline. Her GCS was E4V3M5 and a CT showed a right-sided cribriform plate fracture (Fig. 1, top right) and severe pneumocephalus involving the extradural, subdural, intraventricular, and posterior fossa compartments (Fig. 1). Tension pneumocephalus was excluded as she slowly improved clinically (E4V4M6) and radiologically; the amount of intracranial air gradually reduced on high-flow oxygen. Pneumocephalus is common after neurosurgical and sinus procedures, but also after traumatic base of skull fractures. The Mount Fuji sign refers to tension pneumocephalus, when a ball-valve mechanism leads to air being trapped intracranially, causing brain compression [1]. Pneumocephalus has also been reported after tamponade for epistaxis [2]. We postulated the following mechanism: the patient developed chronic subdural hematoma (CSDH) due to recurrent falls; she suffered a skull base fracture, which allowed the CSDH to leak through the nose. Hence her ‘epistaxis’ was probably a blood-stained CSF leak, which allowed the intracranial pressure to drop, encouraging air to enter the subarachnoid/subdural space, by means of a dehiscence in the skull base, creating a CSF fistula. Figure 2 shows brain reexpansion on follow-up neuroimaging at 10 weeks. In the Mount Fuji sign, the frontal lobes are collapsed by pneumocephalus in the convexity of each hemisphere. The significance of the "twin peaks" sign is two-fold:

Pneumocephalus as a Complication After Facelift Surgery

Following facelift surgery, a number of complications can occur. Some of the most common postoperative facelift complications are hematoma, bleeding, infection, injury to the nerves that control facial muscles, problems with healing of the skin, scarring crust on the incisions, numbness or tingling around the incision areas, skin or hair loss, and skin discoloration.1 The risk of nerve damage or infection after a facelift surgery is low but does exist. We report a case of severe pneumocephalus after facelift, which to our knowledge is the first such report in the literature. A healthy 70-year-old man was referred to us with deep forehead lines resulting from chronic frontalis muscle activity. He sought treatment for brow ptosis and …

Cerebrospinal fluid leakage and pneumocephalus secondary to spine stab wounds

Cerebro-spinal fluid leakage from a spinal stab wound is rare, and usually not a life-threatening injury. Pneumocephalus, a possible rare complication of traumatic cerebro-spinal fluid leakage, can potentially lead to intracranial hemorrhage and death. We describe two cases of spinal stab wounds complicated by cerebro-spinal fluid leakage, one of them developing into severe pneumocephalus. Both patients recovered completely with the following treatment protocol: (a) trendelenburg positioning of the patient, (b) insertion of a continuous-drainage cerebro-spinal fluid catheter into the lumbar thecal sac, (c) primary suture of the leaking skin wound, (d) IV antibiotic therapy.