Delayed Posttraumatic Intraventricular Tension Pneumocephalus

Abstract

Objectives: Pneumocephalus, air in the cranial cavity, is a common occurrence after cranial surgery and less common after head trauma. However, delayed intraventricular tension pneumocephalus, causing a mass effect and abnormal neurological signs as seen in our case, is very rare. Only few cases are reported so far. Understanding the conditions that contribute to tension pneumocephalus, a potentially fatal complication, including the related signs and symptoms, is imperative. Immediate collaboration with a neurosurgeon allows for timely treatment and patient recovery. Treatment measures include preoperative teaching, immediate removal of intracranial air, supine positioning, administration of 100% oxygen, repair of the bony and dural defect, and, if indicated, drain placement into the air cavity, temporary tracheotomy, and antibiotics.Clinical Presentation: A 45-year-old female patient presented with a history of road traffic accident with head trauma. After primary aid, the patient underwent computed tomographic (CT) scan of the head, which showed frontal, small extradural hematoma with pneumocephalus and fractured anterior cranial fossa (left orbital roof). She was managed conservatively and discharged.After 15 days of injury, the patient returned with complaints of drooping of the left eyelid (left oculomotor cranial nerve palsy) and sudden clear fluid nasal discharge (cerebrospinal fluid rhinorrhea). Repeat CT scan showed resolved extradural hematoma and pneumocephalus. Again she was managed conservatively to achieve spontaneous closure of cerebrospinal fluid rhinorrhea in 7 days, and was discharged. After 2 months of injury, she returned the third time with a history of dementia followed by altered sensorium (Glasgow coma score 11 at the time of admission), gait ataxia, vomiting, and urinary incontinence. Clinical features were consistent with those of normal pressure hydrocephalus. Newly taken CT scan of the head showed bifrontal intraventricular tension pneumocephalus.Surgical Intervention: The intraventricular aeroceles were tapped using a twist drill on both sides with evacuation of air. The patient recovered to her full conscious level (Glasgow coma score 15), but showed delayed recovery of urinary incontinence and gait ataxia.Conclusions: Posttraumatic delayed intraventricular "tension pneumocephalus" as seen in our case is a very rare entity, presenting as features mixed with those of normal pressure hydrocephalus and signs of raised intracranial pressure. Immediate tapping is the treatment of choice to reverse deficits and for recovery of the patient. CASE REPORTWe had a 45-year-old female patient who presented to the Department of Accident and Emergency with a history of road traffic accident followed by transient loss of consciousness, vomiting, headache, nasal bleeding, and pain and deformity in the left wrist (Colles fracture). After primary aid, the patient underwent computed tomographic (CT) scan of the head (Figs. 1A, B), which showed left frontal, small extradural hematoma with pneumocephalus...

Tension pneumoventricle in a patient with a ventriculoperitoneal shunt and an ethmoidal meningoencephalocele

“…[ 14 ] The shunt’s possible reduction of intracranial pressure produces a oneway valve as air enters the ventricles but cannot escape from the intracranial compartment. [ 4 , 5 , 22 ] Long-standing intracranial hypertension can produce skull base defects by erosion of the anterior cranial fossa floor. [ 6 ] In those patients who develop a CSF leak, the negative pressure inside the ventricles allows air to enter the ventricles.…”

“…[ 8 , 10 , 13 , 19 ] Symptoms of tension pneumoventricle may include amnesia, headache, aphasia, mutism, gait deterioration, hearing loss, dementia, decline in mental status, agitation, delirium, seizures, focal neurological deficit, progressive loss of consciousness, dilation of pupils, and cardiac arrest. [ 1 , 5 , 11 - 13 , 15 , 16 , 18 - 21 , 24 ] Tension pneumoventricle is usually a neurosurgical emergency requiring urgent treatment. [ 1 , 5 , 8 , 10 ] The etiology should be adequately managed to prevent subsequent episodes.…”

“…[ 1 , 5 , 11 - 13 , 15 , 16 , 18 - 21 , 24 ] Tension pneumoventricle is usually a neurosurgical emergency requiring urgent treatment. [ 1 , 5 , 8 , 10 ] The etiology should be adequately managed to prevent subsequent episodes.…”

“…[ 11 ] Tension pneumoventricle can develop after a skull base fracture. [ 2 , 5 ] Lumbar spinal drainage performed to treat rhinorrhea after head trauma may precipitate the development of tension pneumoventricle. [ 8 ] Spontaneous cerebrospinal fluid (CSF) fistulas had been associated with tension pneumoventricle.…”

Tension pneumoventricle after resection of a fourth ventricle choroid plexus papilloma: An unusual postoperative complication

“…[10] The “valve mechanism” does not allow the air to escape, as the brain's soft tissue blocks the “valve” defect on the exhalation cycle, causing a mass effect and increasing intracranial pressure. [1] Risks also included sudden loss of CSF from enlarged lateral and third ventricles after removal of the tumor in the fourth ventricle,[4] which was opened and explored in the course of surgery. The influx of air into the ventricle is greater in the presence of a noncompliant system because the ventricles do not collapse as the fluid is drained and more air fill it.…”