Pneumocephalus

9 May

submitted by Christina Brown, M.D.

Definition – Air in the cranial vault.  

Mechanically speaking, intracranial air becomes trapped and expands due to a ball valve effect resulting in mass effect, can result in headache and signs and symptoms of increased ICP [5].  

Usually associated with neurosurgery, barotrauma, basilar skull fractures, sinus fractures, nasopharyngeal tumor invasion and meningitis [1, 2].

Presentation

  • Headache and altered consciousness are the most common symptoms [3].
  • Tension pneumocephalus = neurosurgical emergency

Imaging

  • X-rays can diagnose pneumocephalus, but CT scan is the modality of choice.
  • Classical CT sign of tension pneumocephalus = “Mount Fuji sign”: the massive accumulation of air that separates and compresses both frontal lobes and mimics the large volcano in Japan.  

 

Management

Conservative 

  • Neurosurgery C/S. In the vast majority, post-operative pneumocephalus is an expected finding in essentially all post-craniotomy patients.  Most cases of pneumocephalus resolve spontaneously, and conservative management should be provided.  
  • Non-operative management involves oxygen therapy, keeping the head of the bed elevated, prophylactic antimicrobial therapy (especially in post-traumatic cases), analgesia, frequent neurologic checks and repeated CT scans. 

 

Operative – In cases of tension pneumocephalus, a burr hole may need to be performed to relieve pressure. 

 

References

  1. Yildiz A, Duce MN, Ozer C, et al. Disseminated pneumocephalus secondary to an unusual facial trauma. Eur J Radiol. 2002;42:65–68. doi: 10.1016/S0720-048X(01)00383-7. 
  2. Jenson MB, Adams HP. Pneumocephalus after air travel. Neurology. 2004;63:400–401.
  3. Kapoor T, Shetty P. J Emerg Med. 2008;35:453–454. doi: 10.1016/j.jemermed.2007.03.046. 
  4. Satapathy GC, Dash HH. Tension pneumocephalus after neurosurgery in the supine position. Br J Anaesth. 2000;84:115–117. 
  5. Satapathy GC, Dash HH. Tension pneumocephalus after neurosurgery in the supine position. Br J Anaesth. 2000;84 (1): 115-7. Br J Anaesth (abstract)
  6. pictures

 

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