CA S E R EPO RTA 69-year-old man who had previously undergone a craniopharyngioma resection presented with signs and symptoms of meningitis. Computed tomography (CT) cisternography performed at another institution had shown a sellar floor defect, and this was repaired electively at that institution. The sellar floor repair was performed with the patient in a supine position.A combination of propofol and fentanyl was given for anaesthetic induction, and subsequent maintenance was achieved using desflurane. The fraction of inspired oxygen was maintained between 0.34 and 0.45, and no positive end expiratory pressure was set during or after the procedure. Postoperative care of the patient was also conducted in the supine position. Subsequent postsurgical CT evaluation showed minimal, expected pneumocephalus in the temporal horns and sellar region (Fig. 1).The patient's recuperation was complicated by diabetes insipidus. However, after a brief stay in the intensive care unit, the electrolyte imbalance was corrected and steady improvement in the Glasgow Coma Score (GCS) was documented.On postoperative Day 6, the patient experienced spikes of fever and a worsening GCS, for which he received an empirical course of antibiotics. A sudden and further drop in the patient's GCS two days later (from E3V1M5 to E1V2M5) prompted an emergency CT, which showed evidence of tension pneumocephalus, likely due to residual sellar floor defect. Extensive air collections with mass effect were noted in the bilateral subarchnoid spaces, and bilateral dilated frontal and temporal horns (Fig. 2). The patient underwent an emergency burr hole operation and the insertion of a Becker external drainage/monitoring system, with an EDM ventricular catheter (luminal diameter of 1.5 mm), at the right Kocher's point, upon which air under pressure was detected. The air bubbled out when the dura was opened. The external ventricular catheter was kept in situ and the sellar floor was repaired. The patient's GCS subsequently improved and postoperative CT imaging showed considerable reduction in the pneumocephalus with relieved mass effect (Fig. 3).
D I SCU S S IO NTension pneumocephalus is an indication of clinical deterioration due to increased intracranial pressure secondary to pneumocephalus.(1) It occurs when air that enters through a dural defect is unable to escape, akin to a ball-valve ABSTRACT Tension pneumocephalus is a rare but treatable neurosurgical emergency. Prompt and accurate diagnosis of tension pneumocephalus requires a high index of clinical suspicion corroborated by imaging. Herein, we describe a case of extensive tension pneumocephalus in a patient who had undergone transsphenoidal surgery and repair of the sellar floor, with subsequent successful decompression. This case report discusses the pertinent imaging features of tension pneumocephalus and its management.
Tension pneumocephalus
The increasing availability of dual-energy CT (DECT) has set the stage for an exciting era in CT technology. This technique is extensively used throughout the world with numerous centres working on the applications of DECT in various radiology subspeciality areas. DECT provides many advantages over the conventional single-energy scan. Instead of a single set of images, radiologists have access to multiple sets of images from a single acquisition. The DECT workstation enables the reader to generate images, according to the clinical setting, in order to answer a specific clinical question. Radiologists should be aware of the basic concepts of DECT and the usefulness of each image data set. This article aimed to describe the basic principles, techniques and applications of DECT in the imaging of salivary gland lesions. The specific roles of each image data set, in the context of salivary gland lesions, are also discussed.
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