An 80-year-old man presented with generalized weakness and upper
abdominal discomfort. A computed tomography (CT) brain scan showed
hyperpneumatized paranasal sinuses but was otherwise normal ([Fig. 1]).
Fig. 1 Plain computed
tomography (CT) scan showing hyperpneumatized air sinuses.
An esophagogastroscopy was performed which revealed gastritis. He
received intravenous sedation during the procedure but was noted to have been
gagging. He lapsed into coma 5 days later due to a massive tension
pneumocephalus, which was urgently relieved through a burr hole ([Fig. 2]).
Fig. 2 Pneumocephalus after
esophagogastroscopy.
A cisternography demonstrated a cerebrospinal fluid (CSF) fistula at
the left frontal sinus. Surgical repair was performed through a burr hole,
which confirmed the presence of the fistula and a bony defect on the posterior
sinus wall ([Fig. 3]). The patient recovered
well.
Fig. 3 Cerebrospinal fluid
fistula on the posterior wall of the left frontal sinus.
Neurological complications of gastrointestinal endoscopy are
extremely rare; cerebral air embolism has been described, but the occurrence of
pneumocephalus has never been reported [1].
Pneumocephalus is an uncommon but potentially fatal condition. The majority of
cases are traumatic in origin [2]. Spontaneous
pneumocephalus may result from actions which generate high pressure within the
paranasal sinuses, such as Valsalva’s maneuvre [3].
The presence of hyperpneumatized paranasal sinuses may also predispose to
spontaneous pneumocephalus [4]. In the present case, a
sudden rise in airway pressure during endoscopy, albeit transient, was likely
to have resulted in the formation of a CSF fistula through a hyperpneumatized
sinus. The resultant dural tear acted as a ball valve which allowed continuous
inflow of air, and presented with the delayed onset of spontaneous
pneumocephalus.
Spontaneous pneumocephalus may resolve on conservative treatment.
Surgical treatment is indicated when there is evidence of raised intracranial
pressure, neurological deterioration, or when the dural defect does not heal
satisfactorily. We have successfully repaired the CSF fistula through a
craniostomy, although endoscopic frontal outflow tract obliteration may be
considered as a viable, minimally invasive alternative [5].
Endoscopy_UCTN_Code_CPL_1AH_2AJ
