Tension Pneumocephalus From an Eroding Cholesteatoma: A Case Report and Review of the Literature

Abstract

Pneumocephalus is defined as the presence of air inside the cranial vault. Benign and tension pneumocephalus are different ends of the same disease spectrum. Tension pneumocephalus leads to the formation of a pressure gradient, requiring emergent surgical decompression to prevent herniation of the intracranial structures. In this report, we present a rare case of tension pneumocephalus with essentially benign radiological findings secondary to a ruptured cholesteatoma. The patient was a 64-year-old woman with a history of end-stage renal disease on hemodialysis and hypertension. She presented to the emergency department (ED) with acute-onset weakness and decreased mentation. Physical exam findings were consistent with a cerebrovascular accident (CVA). CT scan and CT angiogram (CTA) were unremarkable for ischemia or hemorrhage but showed signs of free intracranial air, consistent with the diagnosis of pneumocephalus. After the activation of the code stroke, neurosurgery and neurology were consulted. Worsening respiratory status led to a decision to proceed with emergent intubation, but it was held based on the family’s decision to proceed with comfort measures. The patient’s status declined further within minutes and she died. Afterward, the case was discussed with the radiologist, who interpreted the cause as a cholesteatoma that had eroded through the temporal bone.

Extensive Pneumocephalus Secondary to Petrous Bone Cholesteatoma

“…3 Radiological study plays a major role in the diagnosis of pneumocephalus, with high-resolution CT and MRI being the main modalities as they have good sensitivity and specificity. 10 CT is usually performed first; it can detect small amounts (.5 mL) of air inside the cranial cavity as well as the location and size of the bony defect. MRI helps to diagnose and localize the defect and identify herniated brain in the ear cavity.…”

“…12 The pressure of the trapped air in tension pneumocephalus results in herniation of the brainstem, compression of the brain parenchyma, and cerebral edema. 10,13 To save patients' lives, emergency decompression is necessary to alleviate pressure on the brain parenchyma. The treatment options include the drilling of burr holes, air aspiration, ventriculostomy, craniotomy, and closure of the defect.…”