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Acute confusion and agitation after epidural anaesthesia: answer
Journal of Clinical Neuroscience (2005) 12(7), 846 0967-5868/$ - see front matter ª 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2005.05.008
Images in neuroscience: answer
Acute confusion and agitation after epidural anaesthesia: answer
ANSWER (b) Pneumocephalus DISCUSSION Our patient had pneumocephalus secondary to epidural anaesthesia. This resulted in an acute confusional state, with rapid cognitive recovery and simultaneous resolution of CT changes over one week. Pneumocephalus, or intracranial gas, is a well-known complication of dural puncture, but has also been described after epidural procedures,1 surgery,2 meningitis,3 air travel,4,5 repeated performance of the Valsalva manouevre,6 nasogastric tube insertion, bag-mask ventilation, endotracheal tube insertion, use of continuous positive airway pressure in patients with head and facial injuries, nitrous oxide anaesthesia and chronic otitis media.5 It may be secondary to a life-threatening process, such as air emboli, neoplasm, infection or trauma.8 The radiographic appearance can be mimicked by artifacts, such as scanning through a nearby trauma board, dense bone, radio-opaque foreign bodies or a stereotactic frame.8 Headache7 and confusion5 have been described in patients with pneumocephalus, especially in the elderly. It is usually benign. Absorption of intracranial air occurs in 85% of cases within the
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first week.5 The remaining 15% are at risk of CSF infection via the dural breach which is allowing air entry.5 Basic management of pneumocephalus is bed rest with the head of the bed elevated. Antibiotics should be used in pneumocephalus secondary to trauma or where there is an ongoing breach of dural integrity.5
REFERENCES 1. Kawamata T, Omote K, Matsumoto M, Toriyabe M, Ito T, Namiki A. Pneumocephalus following an epidural blood patch. Acta Anaesthesiol Scand 2003; 47: 907–909. 2. Sudhakar N, Ray A, Vafidis JA. Complications after trans-sphenoidal surgery: our experience and a review of the literature. Br J Neurosurg 2004; 18: 507–512. 3. Parmar MS. Pneumocephalus associated with Bacteroides fragilis meningitis. J Postgrad Med 2004; 50: 272–273. 4. Jensen MB, Adams HP. Pneumocephalus after air travel. Neurology 2004; 63: 400–401. 5. Chan YP, Yau CY, Lewis RR, Kinirons MT. Acute confusion secondary to pneumocephalus in an elderly patient. Age Ageing 2000; 29: 365–367. 6. Littrell LA, Leutmer PH, Lane JI, Driscoll CL. Progressive calvarial and upper cervical pneumatization associated with habitual valsalva maneuver in a 70-yearold man. AJNR Am J Neuroradiol 2004; 25: 491–493. 7. Kozikowski GP, Cohen SP. Lumbar puncture associated with pneumocephalus: report of a case. Anesth Analg 2004; 98: 524–526. 8. Quint DJ, McGinn G. Intracranial gas: a pictorial essay. Can Assoc Radiol J 1996; 47: 360–364.
Images in neuroscience: answer
Acute confusion and agitation after epidural anaesthesia: answer
ANSWER (b) Pneumocephalus DISCUSSION Our patient had pneumocephalus secondary to epidural anaesthesia. This resulted in an acute confusional state, with rapid cognitive recovery and simultaneous resolution of CT changes over one week. Pneumocephalus, or intracranial gas, is a well-known complication of dural puncture, but has also been described after epidural procedures,1 surgery,2 meningitis,3 air travel,4,5 repeated performance of the Valsalva manouevre,6 nasogastric tube insertion, bag-mask ventilation, endotracheal tube insertion, use of continuous positive airway pressure in patients with head and facial injuries, nitrous oxide anaesthesia and chronic otitis media.5 It may be secondary to a life-threatening process, such as air emboli, neoplasm, infection or trauma.8 The radiographic appearance can be mimicked by artifacts, such as scanning through a nearby trauma board, dense bone, radio-opaque foreign bodies or a stereotactic frame.8 Headache7 and confusion5 have been described in patients with pneumocephalus, especially in the elderly. It is usually benign. Absorption of intracranial air occurs in 85% of cases within the
846
first week.5 The remaining 15% are at risk of CSF infection via the dural breach which is allowing air entry.5 Basic management of pneumocephalus is bed rest with the head of the bed elevated. Antibiotics should be used in pneumocephalus secondary to trauma or where there is an ongoing breach of dural integrity.5
REFERENCES 1. Kawamata T, Omote K, Matsumoto M, Toriyabe M, Ito T, Namiki A. Pneumocephalus following an epidural blood patch. Acta Anaesthesiol Scand 2003; 47: 907–909. 2. Sudhakar N, Ray A, Vafidis JA. Complications after trans-sphenoidal surgery: our experience and a review of the literature. Br J Neurosurg 2004; 18: 507–512. 3. Parmar MS. Pneumocephalus associated with Bacteroides fragilis meningitis. J Postgrad Med 2004; 50: 272–273. 4. Jensen MB, Adams HP. Pneumocephalus after air travel. Neurology 2004; 63: 400–401. 5. Chan YP, Yau CY, Lewis RR, Kinirons MT. Acute confusion secondary to pneumocephalus in an elderly patient. Age Ageing 2000; 29: 365–367. 6. Littrell LA, Leutmer PH, Lane JI, Driscoll CL. Progressive calvarial and upper cervical pneumatization associated with habitual valsalva maneuver in a 70-yearold man. AJNR Am J Neuroradiol 2004; 25: 491–493. 7. Kozikowski GP, Cohen SP. Lumbar puncture associated with pneumocephalus: report of a case. Anesth Analg 2004; 98: 524–526. 8. Quint DJ, McGinn G. Intracranial gas: a pictorial essay. Can Assoc Radiol J 1996; 47: 360–364.