Neurocritical Care

, Volume 13, Issue 1, pp 152–158 | Cite as

Pneumocephalus: Case Illustrations and Review

  • Clemens M. Schirmer
  • Carl B. Heilman
  • Anish Bhardwaj
Review Article

Abstract

Background

Pneumocephalus is commonly encountered after neurosurgical procedures but can also be caused by craniofacial trauma and tumors of the skull base and rarely, can occur spontaneously. Contributing factors for the development of pneumocephalus include head position, duration of surgery, nitrous oxide (N2O) anesthesia, hydrocephalus, intraoperative osmotherapy, hyperventilation, spinal anesthesia, barotauma, continuous CSF drainage via lumbar drain, epidural anesthesia, infections, and neoplasms. Clinical presentation includes headaches, nausea and vomiting, seizures, dizziness, and depressed neurological status. In this article, we review the incidence, mechanisms, precipitating factors, diagnosis, and management of pneumocephalus. Search of Medline, databases, and manual review of article bibliographies. Considering four case illustrations that typify pneumocephalus in clinical practice, we discuss the common etiologies, and confirm the diagnosis with neuroimaging and management strategies. Avoidance of contributing factors, high index of suspicion, and confirmation with neuroimaging are important in attenuating mortality and morbidity. A significant amount of pneumocephalus can simulate a space-occupying lesion. Supplemental oxygen increases the rate of absorption of pneumocephalus.

Keywords

Pneumocephalus Postsurgical Nitrous oxide Mount Fuji sign Air bubble sign 

References

  1. 1.
    Thomas L. Du pneumatocele du crane. Arch Gen Med (Paris). 1866;1:34–55.Google Scholar
  2. 2.
    Chiari H. Uber einen Fall von Luftansammlung in den Ventrikeln des menschlichen Gehirns. Ztschr f Heilk. 1884;5:383–90.Google Scholar
  3. 3.
    Luckett WH. Air in the ventricles of the brain, following a fracture of the skull: report of a case. Surg Gynecol Obstet. 1913;17:237–40.Google Scholar
  4. 4.
    Wolff E. Luftansammlung im rechten Seitenventrikel des Gehirns (Pneumozephalus). Münch Med Wochenschr. 1914;61:899.Google Scholar
  5. 5.
    Markham JW. The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases. Acta Neurochir (Wien). 1967;16:1–78.CrossRefGoogle Scholar
  6. 6.
    Gore PA, Maan H, Chang S, Pitt AM, Spetzler RF, Nakaji P. Normobaric oxygen therapy strategies in the treatment of postcraniotomy pneumocephalus. J Neurosurg. 2008;108:926–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Reasoner DK, Todd MM, Scamman FL, Warner DS. The incidence of pneumocephalus after supratentorial craniotomy. Observations on the disappearance of intracranial air. Anesthesiology. 1994;80:1008–12.CrossRefPubMedGoogle Scholar
  8. 8.
    Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: a retrospective analysis of 488 cases. Neurosurgery. 1984;14:649–58.CrossRefPubMedGoogle Scholar
  9. 9.
    Delgaudio JM, Ingley AP. Treatment of pneumocephalus after endoscopic sinus and microscopic skull base surgery. Am J Otolaryngol. 2009. doi:10.1016/j.amjoto.2009.02.012.
  10. 10.
    Pitts LH, Wilson CB, Dedo HH, Weyand R. Pneumocephalus following ventriculoperitoneal shunt. Case report. J Neurosurg. 1975;43:631–3.CrossRefPubMedGoogle Scholar
  11. 11.
    Little JR, MacCarty CS. Tension pneumocephalus after insertion of ventriculoperitoneal shunt for aqueductal stenosis. J Neurosurg. 1976;44:383–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Caron JL, Worthington C, Bertrand G. Tension pneumocephalus after evacuation of chronic subdural hematoma and subsequent treatment with continuous lumbar subarachnoid infusion and craniostomy drainage. Neurosurgery. 1985;16:107–10.CrossRefPubMedGoogle Scholar
  13. 13.
    Ishiwata Y, Fujitsu K, Sekino T, Fujino H, Kubokura T, Tsubone K, Kuwabara T. Subdural tension pneumocephalus following surgery for chronic subdural hematoma. J Neurosurg. 1988;68:58–61.CrossRefPubMedGoogle Scholar
  14. 14.
    Dowd GC, Molony TB, Voorhies RM. Spontaneous otogenic pneumocephalus. Case report and review of the literature. J Neurosurg. 1998;89:1036–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Mendelsohn DB, Hertzanu Y, Friedman R. Frontal osteoma with spontaneous subdural and intracerebral pneumatocele. J Laryngol Otol. 1984;98:543–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Marras LC, Kalaparambath TP, Black SE, Rowed DW. Severe tension pneumocephalus complicating frontal sinus osteoma. Can J Neurol Sci. 1998;25:79–81.PubMedGoogle Scholar
  17. 17.
    Johnson D, Tan L. Intraparenchymal tension pneumatocele complicating frontal sinus osteoma: case report. Neurosurgery. 2002;50:878–9. discussion 880.CrossRefPubMedGoogle Scholar
  18. 18.
    Clark JB, Six EG. Epidermoid tumor presenting as tension pneumocephalus. Case report. J Neurosurg. 1984;60(6):1312–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Alviedo JN, Sood BG, Aranda JV, Becker C. Diffuse pneumocephalus in neonatal Citrobacter meningitis. Pediatrics. 2006;118:e1576–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Gupta NP, Hemrajani SK, Saluja S, Garg P, Soni A, Kler N. Pneumocephalus in neonatal meningitis. Pediatr Infect Dis J. 2008;27:1118–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Kozikowski GP, Cohen SP. Lumbar puncture associated with pneumocephalus: report of a case. Anesth Analg. 2004;98:524–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Roderick L, Moore DC, Artru AA. Pneumocephalus with headache during spinal anesthesia. Anesthesiology. 1985;62:690–2.CrossRefPubMedGoogle Scholar
  23. 23.
    Goldmann RW. Pneumocephalus as a consequence of barotrauma. JAMA. 1986;255:3154–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Mahabir RC, Szymczak A, Sutherland GR. Intracerebral pneumatocele presenting after air travel. J Neurosurg. 2004;101:340–2.CrossRefPubMedGoogle Scholar
  25. 25.
    Muller J, Hermes M, Piepgras U. Adolf Bingel, the second inventor of lumbar pneumencephalography. AJNR. 1995;16:487–90.PubMedGoogle Scholar
  26. 26.
    Raggio JF, Fleischer AS, Sung YF, Hoffman JC. Expanding pneumocephalus due to nitrous oxide anesthesia: case report. Neurosurgery. 1979;4:261–3.CrossRefPubMedGoogle Scholar
  27. 27.
    Artru AA. Nitrous oxide plays a direct role in the development of tension pneumocephalus intraoperatively. Anesthesiology. 1982;57:59–61.CrossRefPubMedGoogle Scholar
  28. 28.
    Domino KB, Hemstad JR, Lam AM, Laohaprasit V, Mayberg TA, Harrison SD, Grady MS, Winn HR. Effect of nitrous oxide on intracranial pressure after cranial-dural closure in patients undergoing craniotomy. Anesthesiology. 1992;77:421–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Raggio JF. Comment on Black PM et al.: Tension pneumocephalus of the cranial subdural space: a case report. Neurosurgery. 1979;5(3):369.Google Scholar
  30. 30.
    Lunsford LD, Maroon JC, Sheptak PE, Albin MS. Subdural tension pneumocephalus. Report of two cases. J Neurosurg. 1979;50:525–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Hernandez-Palazon J, Martinez-Lage JF, De la Rosa-Carrillo VN, Tortosa JA, López F, Poza M. Anesthetic technique and development of pneumocephalus after posterior fossa surgery in the sitting position. Neurocirugia (Astur). 2003;14:216–21.Google Scholar
  32. 32.
    MacGillivray RG. Pneumocephalus as a complication of posterior fossa surgery in the sitting position. Anaesthesia. 1982;37:722–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Toung T, Donham RT, Lehner A, Alano J, Campbell J. Tension pneumocephalus after posterior fossa craniotomy: report of four additional cases and review of postoperative pneumocephalus. Neurosurgery. 1983;12:164–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Toung TJ, McPherson RW, Ahn H, Donham RT, Alano J, Long D. Pneumocephalus: effects of patient position on the incidence and location of aerocele after posterior fossa and upper cervical cord surgery. Anesth Analg. 1986;65:65–70.PubMedGoogle Scholar
  35. 35.
    Kitahata LM, Katz JD. Tension pneumocephalus after posterior-fossa craniotomy, a complication of the sitting position. Anesthesiology. 1976;44(5):448–50.CrossRefPubMedGoogle Scholar
  36. 36.
    Black PM, Davis JM, Kjellberg RN, Davis KR. Tension pneumocephalus of the cranial subdural space: a case report. Neurosurgery. 1979;5:368–70.CrossRefPubMedGoogle Scholar
  37. 37.
    Friedman GA. Nitrous oxide and the prevention of tension pneumocephalus after craniotomy. Anesthesiology. 1983;58:196–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Friedman GA, Norfleet EA, Bedford RF. Discontinuance of nitrous oxide does not prevent tension pneumocephalus. Anesth Analg. 1981;60:57–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Pandit UA, Mudge BJ, Keller TS, Samra SK, Kilaru P, Pandit SK, Cohen PJ. Pneumocephalus after posterior fossa exploration in the sitting position. Anaesthesia. 1982;37:996–1001.CrossRefPubMedGoogle Scholar
  40. 40.
    Di Lorenzo N, Caruso R, Floris R, Guerrisi V, Bozzao L, Fortuna A. Pneumocephalus and tension pneumocephalus after posterior fossa surgery in the sitting position: a prospective study. Acta Neurochir (Wien). 1986;83(3–4):112–5.CrossRefGoogle Scholar
  41. 41.
    Thiagarajah S, Frost EA, Singh T, Shulman K. Cardiac arrest associated with tension pneumocephalus. Anesthesiology. 1982;56:73–5.CrossRefPubMedGoogle Scholar
  42. 42.
    Cipriani NA, Hong AC, Rosenblum J, Pytel P. Air embolism with pneumocephalus. Arch Neurol. 2009;66:1172–3.CrossRefPubMedGoogle Scholar
  43. 43.
    Eljamel MS, Foy PM. Acute traumatic CSF fistulae: the risk of intracranial infection. Br J Neurosurg. 1990;4(5):381–5.CrossRefPubMedGoogle Scholar
  44. 44.
    Bernal-Sprekelsen M, Bleda-Vazquez C, Carrau RL. Ascending meningitis secondary to traumatic cerebrospinal fluid leaks. Am J Rhinol. 2000;14:257–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Turgut N, Turkmen A, Gokkaya S, Hatiboglu MA, Iplikcioglu AC, Altan A. Positive end-expiratory pressure reduces pneumocephalus in spinal intradural tumor surgery. J Neurosurg Anesthesiol. 2007;19:161–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Eftekhar B, Ghodsi M, Nejat F, Ketabchi E, Esmaeeli B. Prophylactic administration of ceftriaxone for the prevention of meningitis after traumatic pneumocephalus: results of a clinical trial. J Neurosurg. 2004;101:757–61.CrossRefPubMedGoogle Scholar
  47. 47.
    Dexter F, Reasoner DK. Theoretical assessment of normobaric oxygen therapy to treat pneumocephalus. Anesthesiology. 1996;84:442–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Clemens M. Schirmer
    • 1
  • Carl B. Heilman
    • 1
  • Anish Bhardwaj
    • 1
    • 2
  1. 1.Department of Neurological SurgeryTufts University School of MedicineBostonUSA
  2. 2.Department of NeurologyTufts University School of MedicineBostonUSA

Personalised recommendations