Keywords
thoracic surgery - chest wall - lung cancer treatment (surgery medical) - neurology/neurologic
(deficits disease injury)
Introduction
Pneumocephalus following thoracic surgery was first reported in 1974 and since then
it has been rarely described. Most commonly, pneumocephalus can be seen after head
injury with fracture of the skull-base or in cerebral neoplasm, infection, or after
intracranial or spinal surgery. We describe a case of pneumocephalus after thoracic
surgery with posterior chest wall resection and the necessity of neurosurgical operation.
A 69-year-old patient was admitted to hospital with pain in the right thoracic side
and the right shoulder. Computer tomography of the chest showed a T3-tumor in the
right upper lobe with local infiltration of the posterior chest wall. A CT-guided
biopsy was obtained for histological examination, which showed a poorly differentiated
squamous cell lung cancer. The patient received two cycles of neoadjuvant chemotherapy
with cisplatin plus vinorelbine and radiotherapy with 45 Gy. Subsequently, the tumor
size decreased and the patient underwent surgery ([Fig. 1]). Posterolateral thoracotomy was performed with en bloc resection of the right upper
lobe and the involved ribs T2 to T4. Disarticulation of the costotransversal and costovertebral
joints were necessary and chest wall reconstruction was done by Gore-Tex (W.L. Gore
& Associates, Inc., Arizona, United States) dual-mesh prosthesis. For pain relief,
our patient received a thoracic epidural catheter preoperatively.
Fig. 1 Computer tomography of the chest after neoadjuvant therapy.
On the first postoperative day, the patient presented with a sudden reduced vigilance
level, no response to pain stimuli, and anisocoria. CT of the head showed an extensive
pneumocephalus of both hemispheres with a collection of free air in the lateral ventricles
([Fig. 2]). The epidural catheter was removed at once to exclude one of the possible causes
for postoperative pneumocephalus. After two days of conservative therapy with bed
rest in strict supine position of the head and body, the patient was conscious without
anisocoria. Meanwhile, the patient developed a right-sided pneumonia and consecutive
antibiotic therapy was administered. There was a rapid improvement in the patient's
condition with the exception of persistent headache and vertigo. Assuming that intracranial
hypotension was created by a cerebrospinal fistula, the patient was transferred to
the neurosurgical department. In addition, it was assumed that there was an epidural
leakage due to the puncture for epidural catheter placement, thus an epidural blood
patch by autologous donation was made. However, despite the blood patch, the symptoms
of vertigo and headache remained. CT scan of the brain showed a complete decline of
the pneumocephalus and hyperdensity in the external subarachnoid spaces. Chest X-ray
revealed the accumulation of thoracic apical fluid. Under the assumption of a cerebrospinal
fluid fistula with the loss of cerebrospinal fluid into the pleural space, a CT-guided
thoracentesis was performed. Laboratory analysis of the pleural effusion showed high
values of β-trace-protein. Myelography and MRI were carried out for diagnosing and
locating of the subarachnoid-pleural fistula, which was detected at the level of the
T2 to T3 nerve roots ([Fig. 3]). The patient underwent neurosurgery with laminectomy and ligature of the transected
nerve roots. After surgery the patient reported a slow decline of headache and vertigo.
After 1 month, brain pressure was normalized and the patient did well without neurological
symptoms. Two months after the initial thoracic surgical intervention, the patient
was discharged home in good general condition.
Fig. 2 Pneumocephalus of both hemispheres with a collection of free air in the lateral ventricles.
Fig. 3 MRI showed subarachnoid-pleural fistula after chest wall resection.
Comment
Pneumocephalus is a rare but well-known complication. It can be caused by trauma,
neurosurgical procedure, epidural anesthesia, and also as a complication of thoracic
surgical procedures. The body of literature is limited to a few articles after thoracic
surgery.[1]
[2] Symptoms such as headache, vertigo, nausea, vomiting, disorientation, and convulsion
are described and may be a complication of meningitis due to pleuro-subarachnoid fistulas.
Nevertheless, it was discussed whether pleuro-subarachnoid fistulas are often not
recognized in the postoperative course. Moreover, the time till symptoms become evident
may vary. In our case, the patient developed first symptoms on the first postoperative
day, while other authors describe first symptoms between 1 and 8 wk after operation.[1]
[2]
[3]
[4]
[5] Most reported cases of pneumocephalus developed after removal of the chest tube
when intrapleural air extends under positive pressure into the subarachnoid space.[2] Dural tear during rib resections at the costovertebral junction or around the intercostal
nerve root facilitates pleuro-subarachnoid fistulas. CT scan of the brain is mandatory
to verify the diagnosis. The initial treatment encompasses bed rest, flat-head positioning
(Trendelenburg position), and drainage tube placement to control intrathoracic air
pressure. An antibiotic prophylaxis against meningitis should be initiated and the
patient should be monitored neurosurgically.[4]
[5] Complementary or in case of symptom persistence, further investigations should be
performed including MRI and myelographic studies to locate the cerebrospinal fistula.[1] In addition, laboratory tests of the pleural effusion may help to identify a cerebrospinal
leakage. Obliteration of a persistent cerebrospinal fistula should be sought and this
makes laminectomy or a thoracotomy with nerve root ligation usually necessary. After
operation, most of the reported patients showed rapid improvement of their neurological
symptoms.[1]
[3]
