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A case of tension pneumocephalus
Visual Journal of Emergency Medicine 5 (2016) 7–8
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Visual Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/visj
A case of tension pneumocephalus Risa Farber-Heath SUNY Upstate Medical University, 550 East Genesee St, Syracuse, NY 13104, United States
art ic l e i nf o Article history: Received 8 April 2016 Accepted 21 April 2016
Pneumocephalus is often associated with trauma and skull fracture; however, a variety of processes such as infection, lumbar puncture, and other iatrogenic causes have also been implicated. The condition is termed tension pneumocephalus when subsequent increase in intracranial pressure becomes severe enough to cause neurologic compromise.1 We present a case of tension pneumocephalus due to trauma resulting in a residual right abducens (cranial nerve VI) palsy. Our patient is a 61 year old man who was working at a ski resort when he was run over by a 3000 pound snow grooming machine, compressing his head and upper thorax beneath its entire weight. The patient was brought by EMS to the ED with a GCS of 15, and remained alert and awake. He complained of right ear pain, headache, and blurred vision. Examination revealed bright red blood in his right external auditory canal and a right abducens nerve palsy. CT scan revealed tension pneumocephalus and a fracture through the right temporal bone extending through the carotid canal. Fig. 1 is an image from his brain CT scan; multiple air bubbles can be seen in the brain parenchyma as well as a separating of frontal interhemispheric space. Our patient was treated with oxygen via non-rebreather mask and broad-spectrum antibiotics. His recovery was uneventful. The pathophysiology of tension pneumocephalus is unknown, but is generally attributed to one of two possibilities. First is the creation of a ball/valve effect in which a valsalva maneuver causes air to rush into the intracranial space. Second is due to a persistent CSF leak in which negative pressure within the intradural/intracranial space pulls air in through a defect in the calvarium.3 The management of tension pneumocephalus is conservative. Prophylactic antibiotics, elevation of the head of the bed to 30°, avoiding Valsalva pressure, administration of 100% oxygen by face mask, and hyperbaric oxygen therapy have all been used with benefit.1,3 The diagnosis is made by unenhanced CT scan, which E-mail address: [email protected] http://dx.doi.org/10.1016/j.visj.2016.04.004 2405-4690/& 2016 Elsevier Inc. All rights reserved.
often shows separation of the intrahemispheric space of the two frontal lobes with associated subdural air known as the Mount Fuji sign.2,3 The presence of air bubbles scattered throughout the parenchyma and subarachnoid space can also be seen and is known as the “air bubble” sign.2 Focal neurologic deficits, brain herniation, and cerebrospinal fluid leaks which can lead to meningitis are well-known comorbidities of tension pneumocephalus, primarily in the setting of skull fracture.2
Fig. 1. Noncontrast CT head showing tension pneumocephalus with air in bilateral frontal lobes. Note separation of frontal lobes and scattered air bubbles within in the parenchyma.
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R. Farber-Heath / Visual Journal of Emergency Medicine 5 (2016) 7–8
Appendix A. Supplementary material Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.visj.2016.04.004.
References 1. Dabdoub CB, Salas G, Edo N Silveira, Dabdoub CF. Review of the management of pneumocephalus. Surg Neurol Int 2015;6:155http://dx.doi.org/10.4103/ 2152-7806.166195.
2. Schirmer, CM, Heilman, CB, Bhardwaj, A (2010). Pneumocephalus: Case Illustrations and Review. Neurocritical Care. Published online: 20 April 2010. 〈http:// dx.doi.org/10.1007/s12028-010-9363-0〉. 3. Leong KM, Vijayananthan A, Waran V, et al. Pneumocephalus: an uncommon finding in trauma. Med J Malays 2008;63(3):256–258.
Contents lists available at ScienceDirect
HOSTED BY
Visual Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/visj
A case of tension pneumocephalus Risa Farber-Heath SUNY Upstate Medical University, 550 East Genesee St, Syracuse, NY 13104, United States
art ic l e i nf o Article history: Received 8 April 2016 Accepted 21 April 2016
Pneumocephalus is often associated with trauma and skull fracture; however, a variety of processes such as infection, lumbar puncture, and other iatrogenic causes have also been implicated. The condition is termed tension pneumocephalus when subsequent increase in intracranial pressure becomes severe enough to cause neurologic compromise.1 We present a case of tension pneumocephalus due to trauma resulting in a residual right abducens (cranial nerve VI) palsy. Our patient is a 61 year old man who was working at a ski resort when he was run over by a 3000 pound snow grooming machine, compressing his head and upper thorax beneath its entire weight. The patient was brought by EMS to the ED with a GCS of 15, and remained alert and awake. He complained of right ear pain, headache, and blurred vision. Examination revealed bright red blood in his right external auditory canal and a right abducens nerve palsy. CT scan revealed tension pneumocephalus and a fracture through the right temporal bone extending through the carotid canal. Fig. 1 is an image from his brain CT scan; multiple air bubbles can be seen in the brain parenchyma as well as a separating of frontal interhemispheric space. Our patient was treated with oxygen via non-rebreather mask and broad-spectrum antibiotics. His recovery was uneventful. The pathophysiology of tension pneumocephalus is unknown, but is generally attributed to one of two possibilities. First is the creation of a ball/valve effect in which a valsalva maneuver causes air to rush into the intracranial space. Second is due to a persistent CSF leak in which negative pressure within the intradural/intracranial space pulls air in through a defect in the calvarium.3 The management of tension pneumocephalus is conservative. Prophylactic antibiotics, elevation of the head of the bed to 30°, avoiding Valsalva pressure, administration of 100% oxygen by face mask, and hyperbaric oxygen therapy have all been used with benefit.1,3 The diagnosis is made by unenhanced CT scan, which E-mail address: [email protected] http://dx.doi.org/10.1016/j.visj.2016.04.004 2405-4690/& 2016 Elsevier Inc. All rights reserved.
often shows separation of the intrahemispheric space of the two frontal lobes with associated subdural air known as the Mount Fuji sign.2,3 The presence of air bubbles scattered throughout the parenchyma and subarachnoid space can also be seen and is known as the “air bubble” sign.2 Focal neurologic deficits, brain herniation, and cerebrospinal fluid leaks which can lead to meningitis are well-known comorbidities of tension pneumocephalus, primarily in the setting of skull fracture.2
Fig. 1. Noncontrast CT head showing tension pneumocephalus with air in bilateral frontal lobes. Note separation of frontal lobes and scattered air bubbles within in the parenchyma.
8
R. Farber-Heath / Visual Journal of Emergency Medicine 5 (2016) 7–8
Appendix A. Supplementary material Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.visj.2016.04.004.
References 1. Dabdoub CB, Salas G, Edo N Silveira, Dabdoub CF. Review of the management of pneumocephalus. Surg Neurol Int 2015;6:155http://dx.doi.org/10.4103/ 2152-7806.166195.
2. Schirmer, CM, Heilman, CB, Bhardwaj, A (2010). Pneumocephalus: Case Illustrations and Review. Neurocritical Care. Published online: 20 April 2010. 〈http:// dx.doi.org/10.1007/s12028-010-9363-0〉. 3. Leong KM, Vijayananthan A, Waran V, et al. Pneumocephalus: an uncommon finding in trauma. Med J Malays 2008;63(3):256–258.