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.
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.
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.
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.
Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
Reprints: Sarbjit Singh Chhiber, MCh, Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India (e-mail: email@example.com).