Download PDF
J Neurol Surg A Cent Eur Neurosurg 2013; 74(S 01): e96-e99
DOI: 10.1055/s-0032-1328954
Case Report
Georg Thieme Verlag KG Stuttgart · New York

Intraventricular Tension Pneumocephalus after Endoscopic Skull Base Surgery

Antonios Mammis
1   Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, United States
,
Nitin Agarwal
1   Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, United States
,
Jean Anderson Eloy
1   Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, United States
2   Department of Otolaryngology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States
,
James K. Liu
1   Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, United States
2   Department of Otolaryngology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States
› Author Affiliations
Further Information

Publication History

19 December 2011

12 May 2012

Publication Date:
20 February 2013 (online)

    Permissions and Reprints

Abstract

Background and Study Aims Postoperative pneumocephalus is commonly observed after neurosurgical intracranial procedures and is usually of little consequence. Intraventricular tension pneumocephalus, however, is a rare complication and a neurosurgical emergency that requires immediate intervention. We describe the first case of intraventricular tension pneumocephalus that developed 1 week following an expanded endoscopic endonasal approach for resection of a suprasellar mass.

Patient A patient who underwent an endoscopic transplanum transtuberculum approach for resection of a suprasellar epidermoid tumor developed a sudden change in mental status, with imaging consistent with intraventricular tension pneumocephalus. Immediate endotracheal intubation and placement of an external ventricular drain prevented further deterioration. Endoscopic exploration of the skull base reconstruction revealed a one-way ball valve mechanism as the source of pneumocephalus. The skull base reconstruction was revised with autologous fascia lata and repositioning of the pedicled nasoseptal flap.

Conclusion Intraventricular tension pneumocephalus is a rare neurosurgical emergency that may develop after endoscopic skull base surgery. Initial management includes endotracheal intubation and placement of an external ventricular drain to decompress the ventricles. Endoscopic exploration and revision of the skull base repair is imperative to obliterate the ball-valve fistula to prevent further entrapment of air.

Keywords

intraventricular tension pneumocephalus - endoscopic skull base surgery - endoscopic endonasal transplanum transtuberculum approach - suprasellar tumor - expanded endonasal approach
 

  • References

  • 1 Dandy WE. Pneumocephalus (intracranial pneumatocele or aerocele). Arch Surg 1926; 132: 949-982
    PubMedGoogle Scholar
  • 2 Wolf S, Spielman F. Tension pneumocephalus. Neurosurgery 1981; 8: 514
    CrossrefPubMedGoogle Scholar
  • 3 Worthington C, Caron JL, Bertrand G. Tension pneumocephalus. Neurosurgery 1985; 17: 379-380
    CrossrefPubMedGoogle Scholar
  • 4 Mammis A, Yanni D, Gupta G, Karimi R, Schulder M. Relief of tension pneumocephalus with endotracheal intubation. Surg Neurol 2009; 71: 392-394
    CrossrefPubMedGoogle Scholar
  • 5 Kitahata LM, Katz JD. Tension pneumocephalus after posterior-fossa craniotomy, a complication of the sitting position. Anesthesiology 1976; 44: 448-450
    CrossrefPubMedGoogle Scholar
  • 6 Lunsford LD, Maroon JC, Sheptak PE, Albin MS. Subdural tension pneumocephalus. Report of two cases. J Neurosurg 1979; 50: 525-527
    CrossrefPubMedGoogle Scholar
  • 7 Heckmann JG, Ganslandt O. Images in clinical medicine. The Mount Fuji sign. N Engl J Med 2004; 350: 1881
    CrossrefPubMedGoogle Scholar
  • 8 Sadeghian H. Mount Fuji sign in tension pneumocephalus. Arch Neurol 2000; 57: 1366
    CrossrefPubMedGoogle Scholar
  • 9 Ruelle A, Severi P, Andrioli G. Intraventricular pneumocephalus after posterior fossa and CSF shunting surgery. Case report. J Neurosurg Sci 1994; 38: 167-170
    PubMedGoogle Scholar
  • 10 Mineo JF, Phong DH, Seizeur R, Mériot P, Besson G. Delayed isolated tension intraventricular pneumocephalus after ventriculoperitoneal shunt. Neurochirurgie 2004; 50: 96-100
    PubMedGoogle Scholar
  • 11 Jea A, Baskaya MK, Farhat H, Benglis D, Zauner A. Pneumocephalus in a patient with a ventriculoperitoneal shunt after percutaneous gastrojejunostomy catheter placement: case report. Surg Neurol 2006; 65: 87-89 , discussion 89
    CrossrefPubMedGoogle Scholar
  • 12 Sasani M, Ozer FA, Oktenoglu T, Tokatli I, Sarioglu AC. Delayed and isolated intraventricular tension pneumocephalus after shunting for normal pressure hydrocephalus. Neurol India 2007; 55: 81-82
    PubMedGoogle Scholar
  • 13 Garg N, Devi I, Dua R, Arivazhagan A. Tension pneumoventricle following exposure of shunt chamber. Br J Neurosurg 2008; 22: 121-122
    CrossrefPubMedGoogle Scholar
  • 14 Tuğcu B, Tanriverdi O, Günaldi O, Baydin S, Postalci LS, Akdemir H. Delayed intraventricular tension pneumocephalus due to scalp-ventricle fistula: a very rare complication of shunt surgery. Turk Neurosurg 2009; 19: 276-280
    PubMedGoogle Scholar
  • 15 Sawka AM, Aniszewski JP, Young Jr WF, Nippoldt TB, Yanez P, Ebersold MJ. Tension pneumocranium, a rare complication of transsphenoidal pituitary surgery: Mayo Clinic experience 1976-1998. J Clin Endocrinol Metab 1999; 84: 4731-4734
    CrossrefPubMedGoogle Scholar
  • 16 Rao G, Apfelbaum RI. Symptomatic pneumocephalus occurring years after transphenoidal surgery and radiation therapy for an invasive pituitary tumor: a case report and review of the literature. Pituitary 2003; 6: 49-52
    CrossrefPubMedGoogle Scholar
  • 17 Andrews JC, Canalis RF. Otogenic pneumocephalus. Laryngoscope 1986; 96: 521-528
    CrossrefPubMedGoogle Scholar
  • 18 Por YC, Barcelo CR, Salyer KE. Extradural tension pneumocephalus after posterior cranial vault remodeling for ventriculoperitoneal shunt-induced craniosynostosis. J Craniofac Surg 2005; 16: 504-508
    CrossrefPubMedGoogle Scholar
  • 19 Vitali AM, Roux A. Tension pneumocephalus as a complication of intracranial pressure monitoring: a case report. Indian J Neurotrauma 2007; 4: 115-118
    PubMedGoogle Scholar