Air travel after intracranial surgery: a survey of advice given to patients by consultant neurosurgeons in the UK

Amato-Watkins, Anthony; Rao, Veeru Mudigunda; Leach, Philip

doi:10.3109/02688697.2012.716176

Cited by 9 publications

(13 citation statements)

References 4 publications

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“…These findings confirm that some post-surgery subdural hematoma patients have intracranial air post-operatively [3, 13, 15]. …”

Section: Discussionsupporting

confidence: 79%

“…If intracranial air is present post-operatively [1, 2], for example after the surgical evacuation of an intracranial expansive lesion, it will also be resorbed over time, over weeks [3, 4]. In modern, centralized, specialty care, patients receiving neurosurgical operative interventions (commonly borr hole or mini-craniotomy) at a tertiary care hospital may be transported back to their home hospital early after their operation accompanied by critical care personnel [5, 6], where post-operative intracranial air (if present) has not yet been resorbed.…”

Section: Introductionmentioning

confidence: 99%

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Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation

Brändström

Sundelin

Hoseason

et al. 2017

Scand J Trauma Resusc Emerg Med

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BackgroundPost-craniotomy intracranial air can be present in patients scheduled for air ambulance transport to their home hospital. We aimed to assess risk for in-flight intracranial pressure (ICP) increases related to observed intracranial air volumes, hypothetical sea level pre-transport ICP, and different potential flight levels and cabin pressures.MethodsA cohort of consecutive subdural hematoma evacuation patients from one University Medical Centre was assessed with post-operative intracranial air volume measurements by computed tomography. Intracranial pressure changes related to estimated intracranial air volume effects of changing atmospheric pressure (simulating flight and cabin pressure changes up to 8000 ft) were simulated using an established model for intracranial pressure and volume relations.ResultsApproximately one third of the cohort had post-operative intracranial air. Of these, approximately one third had intracranial air volumes less than 11 ml. The simulation estimated that the expected changes in intracranial pressure during ‘flight’ would not result in intracranial hypertension. For intracranial air volumes above 11 ml, the simulation suggested that it was possible that intracranial hypertension could develop ‘inflight’ related to cabin pressure drop. Depending on the pre-flight intracranial pressure and air volume, this could occur quite early during the assent phase in the flight profile.DiscussionThese findings support the idea that there should be radiographic verification of the presence or absence of intracranial air after craniotomy for patients planned for long distance air transport.ConclusionsVery small amounts of air are clinically inconsequential. Otherwise, air transport with maintained ground-level cabin pressure should be a priority for these patients.

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“…These findings confirm that some post-surgery subdural hematoma patients have intracranial air post-operatively [3, 13, 15]. …”

Section: Discussionsupporting

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation

Brändström

Sundelin

Hoseason

et al. 2017

Scand J Trauma Resusc Emerg Med

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“…Two British studies focused on the medical advice given to post-craniotomy patients regarding air travel and addressed the unstandardized approach of airline companies and insufficient consensus among practicing consultant neurosurgeons2,13).…”

Section: Discussionmentioning

confidence: 99%

Barotrauma-Induced Pneumocephalus Experienced by a High Risk Patient after Commercial Air Travel

Huh

2013

J Korean Neurosurg Soc

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A 49-year-old female with a history of several neurosurgical and otolaryngologic procedures for occipital meningioma and cerebrospinal fluid leaks was diagnosed with pneumocephalus after a one hour flight on a domestic jet airliner. Despite multiple operations, the air appeared to enter the cranium through a weak portion of the skull base due to the low atmospheric pressure in the cabin. The intracranial air was absorbed with conservative management. The patient was recommended not to fly before a definite diagnostic work up and a sealing procedure for the cerebrospinal fluid leak site had been performed. Recent advances in aviation technology have enabled many people to travel by air, including individuals with medical conditions. Low cabin pressure is not dangerous to healthy individuals; however, practicing consultant neurosurgeons should understand the cabin environment and prepare high risk patients for safe air travel.

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“…The lack of clarity on air travel safety among post-operative neurosurgical patients is further demonstrated by the absence of consensus amongst neurosurgeons when addressing post-neurosurgery air travel. A survey conducted by Amato-Watkins et al 13 revealed that 5 out of 66 neurosurgeons were against air travel after neurosurgery, with the remaining 61 recommending an air travel restriction period ranging from 2 to 8 weeks 13 . The UK Civil Aviation Authority recommends that patients avoid flying in the first week after intracranial surgery 13 .…”

mentioning

confidence: 99%

“…A survey conducted by Amato-Watkins et al 13 revealed that 5 out of 66 neurosurgeons were against air travel after neurosurgery, with the remaining 61 recommending an air travel restriction period ranging from 2 to 8 weeks 13 . The UK Civil Aviation Authority recommends that patients avoid flying in the first week after intracranial surgery 13 . A survey conducted by Seth et al 2 on 17 commercial airlines revealed that only three of them were able to provide detailed advice on whether post-craniotomy patients should embark on air travel.…”

mentioning

confidence: 99%

Pneumocephalus and air travel: an experimental investigation on the effects of aircraft cabin pressure on intracranial pressure

Lim

Lan

Ooi

et al. 2020

Sci Rep

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This study investigates the effects of aircraft cabin pressure on intracranial pressure (ICP) elevation of a pneumocephalus patient. We propose an experimental setup that simulates the intracranial hydrodynamics of a pneumocephalus patient during flight. It consists of an acrylic box (skull), air-filled balloon [intracranial air (ICA)], water-filled balloon (cerebrospinal fluid and blood) and agarose gel (brain). The cabin was replicated using a custom-made pressure chamber. The setup can measure the rise in ICP during depressurization to levels similar to that inside the cabin at cruising altitude. ΔICP, i.e. the difference between mean cruising ICP and initial ICP, was found to increase with ICA volume and ROC. However, ΔICP was independent of the initial ICP. The largest ΔICP was 5 mmHg; obtained when ICA volume and ROC were 20 ml and 1,600 ft/min, respectively. The postulated ICA expansion and the subsequent increase in ICP in pneumocephalus patients during flight were successfully quantified in a laboratory setting. Based on the quantitative and qualitative analyses of the results, an ICA volume of 20 ml and initial ICP of 15 mmHg were recommended as conservative thresholds that are required for safe air travel among pneumocephalus patients. This study provides laboratory data that may be used by doctors to advise post-neurosurgical patients if they can safely fly. Craniotomy refers to the surgical removal of a portion of the skull to gain access to the contents of the intracranial cavity. The procedure usually involves exposing the brain after opening its membranous coverings 1 , which inevitably expose the human brain to surrounding air. Varying amounts of air within the intracranial cavity (ICA) (known as pneumocephalus) remain after craniotomy 2. In most cases, pneumocephalus is not life-threatening as the ICA is normally absorbed into the systemic circulation over a period of several weeks 3-5. Safety concerns arise when patients with pneumocephalus engage in air travel before the ICA is fully absorbed. Air safety regulations require cabins of commercial aircraft to be pressurized to a standardized minimum of 75 kPa, which is approximately 75% that of atmospheric pressure at sea level (101.3 kPa), at cruising altitude 6,7. Consequently, during air travel, the ambient pressure may be as much as 25 kPa lower than the initial pressure of the ICA, which is at 101.3 kPa. According to Boyle's law, the difference in pressure between the aircraft cabin and the ICA would result in an increase in the ICA volume, as the ICA expands to equilibrate with the cabin pressure. The expansion, which takes place inside the rigid cranium, may cause cerebral compression that can lead to elevations in the intracranial pressure (ICP). A mild increase in ICP is tolerable. However, if the increase in ICP is too large, cerebral herniation may occur, which severely endangers the life of the pneumocephalus patient. In spite of the potential life-threatening event, pneumocephalus and air travel safety remains a controversial topic 8...

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Air travel after intracranial surgery: a survey of advice given to patients by consultant neurosurgeons in the UK

Abstract: Clinical practice varies widely due to a lack of clear evidence, standards or guidelines. Should the SBNS be producing national guidelines to standardise the advice given to patients?

Cited by 9 publications

References 4 publications

Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation

Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation

Barotrauma-Induced Pneumocephalus Experienced by a High Risk Patient after Commercial Air Travel

Pneumocephalus and air travel: an experimental investigation on the effects of aircraft cabin pressure on intracranial pressure

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