Tension Pneumocranium, a Rare Complication of Transsphenoidal Pituitary Surgery: Mayo Clinic Experience 1976–1998

Abstract

We describe four cases of symptomatic pneumocranium, a rare, potentially life-threatening complication of transsphenoidal pituitary surgery. Symptomatic pneumocranium manifested as impaired mental status, headaches, and grand mal seizures, early in the postoperative course after transsphenoidal pituitary surgery. Furthermore, a Cushing response, including systemic hypertension and bradycardia (secondary to intracranial hypertension) was seen, which has not been previously described in association with symptomatic pneumocranium. We describe a previously unreported risk factor for tension pneumocranium, untreated obstructive sleep apnea. Other factors predisposing to tension pneumocranium in our patients included: cerebrospinal fluid leaks, postoperative positive-pressure mask ventilation, large pituitary tumors, and intraoperative lumbar drainage catheters. Surgical drainage of the pneumocranium and repair of any coexistent cerebrospinal fluid leak markedly improved neurologic status. Symptomatic pneumocranium occurring early in the postoperative course after transsphenoidal pituitary surgery is rare, but prompt recognition and treatment of this condition can be life-saving.

Cerebrospinal Fluid Leakage During Transsphenoidal Surgery: Postoperative External Lumbar Drainage Reduces the Risk for Meningitis

“…According to our peroperative protocol, the ELD was removed on the fifth day in most patients, which may explain why we did not observe any lumbar catheterrelated infections. Symptomatic pneumocephalus due to lumbar CSF-drainage is another rare, life-threatening complication, which did not occur in the present series [25,26].…”

Middle ear pressure during sleep and the effects of continuous positive airway pressure

“…A study conducted in guinea pigs demonstrated that elevating MEP with air up to 250 daPa had no effect on auditory thresholds measured by auditory brainstem response (ABR) [8]. While it appears that hearing is likely not significantly affected in most individuals, there have been rare reports of tympanic membrane rupture, pneumocephalus, and tension pneumocranium with CPAP use [9][10][11][12]. Although rare, these findings should prompt caution with CPAP use following head trauma, rhinologic or otologic surgery, and particularly following intradural skull base procedures.…”

Polyethylene glycol (PEG) hydrogel dural sealant and collagen dural graft matrix in transsphenoidal pituitary surgery for prevention of postoperative cerebrospinal fluid leaks

“…26 Another, but rare, complication of postoperative CSF leak following TSS is tension pneumocephalus. 27 Meticulous closure of the sellar defect has been advocated to prevent complications. Unfortunately, a limited working space and complex anatomy of the sinuses have resulted in marginal success.…”