Pneumocephalus Following Air Travel in a Patient With Preexisting Facial Fractures and Dural Tears

Chue, Koy Min; Lim, Thiam Chye; Lim, Jane; Yap, Yan Lin; Ong, Wei Chen

doi:10.1097/scs.0000000000002919

Cited by 5 publications

(9 citation statements)

References 11 publications

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“…One patient suffered multiple facial fractures and a dural tear on his way to the airport and without neurologic deterioration in-flight eventually presented to the emergency department with an extensive pneumocephalus [ 6 ]. The CT scan 7 days after surgery, including cranialisation of the frontal and ethmoidal sinuses as well as repair of the dural tear using a vascularised pericranial flap, showed minimal pneumocephalus.…”

Section: Discussionmentioning

confidence: 99%

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Air travel with pneumocephalus: a systematic review

2022

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Introduction Concerns arise when patients with pneumocephalus engage in air travel. How hypobaric cabin pressure affects intracranial air is largely unclear. A widespread concern is that the intracranial volume could relevantly expand during flight and lead to elevated intracranial pressure. The aim of this systematic review was to identify and summarise models and case reports with confirmed pre-flight pneumocephalus. Methods The terms (pneumocephalus OR intracranial air) AND (flying OR fly OR travel OR air transport OR aircraft) were used to search the database PubMed on 30 November 2021. This search returned 144 results. To be included, a paper needed to fulfil each of the following criteria: (i) peer-reviewed publication of case reports, surveys, simulations or laboratory experiments that focussed on air travel with pre-existing pneumocephalus; (ii) available in full text. Results Thirteen studies met the inclusion criteria after title or abstract screening. We additionally identified five more articles when reviewing the references. A notion that repeatedly surfaced is that any air contained within the neurocranium increases in volume at higher altitude, much like any extracranial gas, potentially resulting in tension pneumocephalus or increased intracranial pressure. Discussion Relatively conservative thresholds for patients flying with pneumocephalus are suggested based on models where the intracranial air equilibrates with cabin pressure, although intracranial air in a confined space would be surrounded by the intracranial pressure. There is a discrepancy between the models and case presentations in that we found no reports of permanent or transient decompensation secondary to a pre-existing pneumocephalus during air travel. Nevertheless, the quality of examination varies and clinicians might tend to refrain from reporting adverse events. We identified a persistent extracranial to intracranial fistulous process in multiple cases with newly diagnosed pneumocephalus after flight. Finally, we summarised management principles to avoid complications from pneumocephalus during air travel and argue that a patient-specific understanding of the pathophysiology and time course of the pneumocephalus are potentially more important than its volume.

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Section: Discussionmentioning

confidence: 99%

“…The patient was allowed to fly home again and has since made a complete recovery. Fistulous processes can also appear after barotrauma from air-filled sinuses or mastoid air cells [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

Air travel with pneumocephalus: a systematic review

2022

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“…In spite of the potential life-threatening event, pneumocephalus and air travel safety remains a controversial topic 8 . Cases of post-neurosurgical patients embarking on commercial air travel have been recorded in the past.…”

Section: Introductionmentioning

confidence: 99%

“…For instance, Beda et al 9 reported on a parietotemporal craniectomy patient who developed deteriorating neurological condition and confirmed intraparenchymal pneumocephalus after embarking on air travel. Chue et al 8 reported on the development of extensive pneumocephalus in a facial trauma patient who engaged in air travel post-injury. However, there were no reported neurological symptoms.…”

Section: Introductionmentioning

confidence: 99%

“…Much of the advice used by the industry and the medical profession is not evidenced-based and relies on case reports, cranial CT scans in symptomatic patients following flights or mathematical models 14 . This is not surprising given the difficulties of performing in-flight brain imaging or ICP monitoring, which has prompted calls for more research into this topic 8,15 . There is currently insufficient information to show a direct correlation between the volume of intracranial air and changes in intracranial pressure during air travel.…”

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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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Orbital Fractures and Air Travel

Riordan

Rijt

Kernohan

2021

Journal of Craniofacial Surgery

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Previous surveys indicate that the majority of clinicians recommend avoidance of air travel for a period of time following an acute orbital fracture. This advice has largely been based on the theoretical risk that in-flight pressure variation may exacerbate orbital emphysema and produce visual compromise, though no previous reviews have been conducted on the evidence underpinning this advice. The purpose of this study was, therefore, to conduct a systematic review of the literature pertaining to the safety of air travel in the setting of an acute orbital fracture. A systematic review of the OVID Medline database -and of cases referenced as providing evidence for adverse outcomes due to flying with an orbital fracturewas carried out.Two articles were identified from the literature with data specific to patients who undertook air travel following orbital fractures. A large case series identified no complications in patients exposed to both pressurized and unpressurized air travel, and only a single case report detailed an adverse outcome requiring intervention. The remainder of the articles that had previously been cited as evidence against air travel involved additional factors such as intraocular pathologies. There is, therefore, a paucity of evidence to support the conventional advice regarding avoidance of air travel, though clinicians should exclude the possibility of an associated intra-ocular injury, advise against nose-blowing in flight, and provide advice regarding alternative methods to the Valsalva maneuver for equalizing middle ear pressure in flight. Level of Evidence: IV

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Pneumocephalus Following Air Travel in a Patient With Preexisting Facial Fractures and Dural Tears

Cited by 5 publications

References 11 publications

Air travel with pneumocephalus: a systematic review

Air travel with pneumocephalus: a systematic review

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

Orbital Fractures and Air Travel

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