- Email: [email protected]
Successful treatment of epidural anesthesia–induced severe pneumocephalus by hyperbaric oxygen therapy
Successful treatment of epidural anesthesia induced severe pneumocephalus by hyperbaric oxygen therapy Chang-Chih Shih, Shih-Hung Tsai, Wen-I Liao, Jen-Chun Wang, ChinWang Hsu PII: DOI: Reference:
S0735-6757(15)00046-7 doi: 10.1016/j.ajem.2015.01.044 YAJEM 54773
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
20 January 2015 23 January 2015
Please cite this article as: Shih Chang-Chih, Tsai Shih-Hung, Liao Wen-I, Wang JenChun, Hsu Chin-Wang, Successful treatment of epidural anesthesia induced severe pneumocephalus by hyperbaric oxygen therapy, American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.01.044
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Case report
T
Successful treatment of epidural anesthesia induced severe
Chang-Chih Shih, 2Shih-Hung Tsai, 2Wen-I Liao, 2Jen-Chun Wang, 1Chin-Wang Hsu*
Department
of
Emergency and
Critical
Care
Medicine,
Taipei
Medical
MA NU
1
SC
2
RI P
pneumocephalus by hyperbaric oxygen therapy
University-Wan Fang Hospital, Taipei, Taiwan 2
Department of Emergency Medicine, Tri-Service General Hospital, National Defense
ED
Medical Center, Taipei, Taiwan
PT
Financial support or interest: none *Corresponding to:
CE
Chin-Wang Hsu, M.D.,
Department of Emergency and Critical Care Medicine,
AC
Taipei Medical University-Wan Fang Hospital, Taipei No.111, Sec. 3, Hsing-Long Rd., Taipei 116, Taiwan Tel: +886-2-29307930; Fax: +886-2-2795-5682 E-mail: [email protected]
Keywords: pneumocephalus, epidural anesthesia, hyperbaric oxygen therapy
1
ACCEPTED MANUSCRIPT Abstract
T
Pneumocephalus is a rare complication after using loss-of-resistance to air (LOR-A)
RI P
technique of epidural anesthesia, and is usually caused by inadvertent dural
SC
puncture. Most patients with pneumocephalus have headache, motor weakness, seizures, and focal neurologic deficits depend on the distribution and amount of
MA NU
intracranial air. Consciousness decline and death had been reported due to mass effect or cerebral gas embolism. Either conservative treatment with 100% oxygen and ventilator support or surgical intervention with external ventricular drain had
ED
been reported as a treatment. We present a 36-year-old otherwise healthy woman
PT
with cardiopulmonary arrest and deep coma as a complication of LOR-A epidural
CE
anesthesia. She regained consciousness rapidly 3 hours after completion of
AC
one-session of 120 minutes emergent hyperbaric oxygen therapy (HBOT) at 2.8 atmospheres absolute pressure with 100% oxygen concentration. Our successful treatment provides a new insight for the use of HBOT in the management of epidural procedure induced life-threatening pneumocephalus.
2
ACCEPTED MANUSCRIPT Pneumocephalus after loss-of-resistance to air (LOR-A) technique of epidural
T
anesthesia is rare [1]. Headache and focal neurologic deficits may present very
RI P
depend on the distribution and amount of the intracranial air; but devastating
SC
complication could be developed. Here we report a patient who developed coma and cardiopulmonary arrest due to epidural anesthesia induced pneumocephalus. She
MA NU
recovered rapidly after treated with hyperbaric oxygen therapy (HBOT).
A 36-year-old otherwise healthy woman was transferred to our emergency
ED
department because of altered consciousness after the procedure of epidural
PT
anethesia. She had been scheduled for cystectomy for endometrioma of ovary at
CE
another gynecological clinic. She developed altered consciousness and
AC
cardiopulmonary arrest soon after the end of LOR-A technique-based epidural anesthesia procedure. Emergent endotracheal tube intubation and cardiopulmonary resuscitation were performed accordingly. On arrival, her blood pressure was 108/51 mmHg, pulse rate 102 beats/min, respiration rate 21 breaths/min, and body temperature 35.5℃. Neurological examinations revealed coma with a Glasgow Coma Scale three (Eyes one, Motor one, Verbal one, intubated) and absence of suction reflex and oculocephalic reflex, indicating dysfunction of brainstem. Cranial computed tomography (CT) without contrast enhancement showed an air 3
ACCEPTED MANUSCRIPT accumulation in the cerebrospinal fluid space of the skull base region anterior to the
T
brainstem (Figure 1). A diagnosis of severe pneumocephalus due to brainstem
RI P
compression was made. She regained consciousness rapidly 3 hours after completion
SC
of one-session of 120 minutes emergent hyperbaric oxygen therapy (HBOT) at 2.8 atmospheres absolute pressure with 100% oxygen concentration. She was extubated
retained neurological sequelae.
MA NU
13 hours after HBOT and discharged on the eighth hospital day in the absence of any
ED
To the best our knowledge, here we present for the first time that HBOT could rapidly
PT
ameliorate severe neurological deficit due to epidural anesthesia induced
CE
pneumocephalus. Pneumocephalus is defined as accumulation of air within the
AC
cranium, which is usually associated with trauma, neoplasm, infection and surgical intervention. Less than 3% of patients developed pneumocephalus after epidural anesthesia while using LOR-A technique [2]. This complication is usually caused by inadvertent dural puncture. Most patients with pneumocephalus had headache (40%), motor weakness (12%), seizures (8%), and acute delirium (5%) [3]. Nonetheless, altered consciousness and death had been reported due to mass effect or cerebral gas embolism [4, 5]. We reviewed and summarized the reported cases of epidural injection or anesthesia associated pneumocephalus with severe 4
ACCEPTED MANUSCRIPT complications, including loss of consciousness, cardiopulmonary arrest and death
T
(Table 1). Among these cases, the common etiologies were dural breach. All the
RI P
summarized cases were treated conservatively, including administration of 100%
SC
oxygen, fluid supplement and ventilation support, rather than surgical intervention. The duration of the recovery were more than 3 days in those patients. The severity of
MA NU
neurologic deficient is generally associated with the volume of the air and its mass effect. Nevertheless, it also related to the location and distribution of the intracranial air; even a small quantity of intracranial air collected in the limited space of the
ED
posterior fossa can cause significantly increased intracranial pressure, hence
PT
respiratory arrest [6]. The combination of deep coma in the absence of main
CE
brainstem reflex in the neurologic examination and pneumocephalus in the cisternal
AC
region anterior to the brainstem in the cranial CT supported that cardiopulmonary arrest followed by prolonged deep coma may be due to the compression of brainstem by the accumulated intracranial air in this patient. Conservative treatment for pneumocephalus is breathing 100% oxygen, which increases the rate of absorption of intracranial air [5]. Decompression with emergent craniotomy or evacuation of trapped air with external ventricular drain may be required for severe complications of pneumocephalus [6]. Notwithstanding, it is difficult and dangerous to aspirate the accumulated air surrounding to brainstem. HBOT is the main-stay-of 5
ACCEPTED MANUSCRIPT treatment for decompression sickness while bubble formation in tissues can result in
T
mechanical disruption of tissue, occlusion of blood flow, platelet activation,
RI P
endothelial dysfunction and capillary leakage [7]. According to Boyle's Law, the
SC
volume of nitrogen bubbles is inversely related to the pressure and dissolution is also accomplished by the replacement of oxygen [7]. HBOT is therefore putatively able to
MA NU
reduce air bubbles size in this case. Our experience was in line with a previous study regarding average of 8.8 exposures of HBOT at 2.5 atmospheres ameliorated headache and neurological deterioration due to pneumocephalus due to trauma or
ED
surgery in a selected group of 13 patients (excluded patients with endotracheal
PT
intubation or Glasgow Coma Scale scores less than 13 points) [8]. Another report also
CE
mentioned that in the patients with trauma or post-neurosurgery associated
AC
pneumocephalus, dramatic improvement in the neurologic symptoms, such as somnolence, mental confusion, paretic limbs, and acute pain could be achieved with 2 to 7 sessions of HBOT at 2.5 atmospheres[9]. Taken together, we believe that HBOT could have beneficial effects on the acute treatment of severe pneumocephalus.
In conclusion, pneumocephalus caused by inadvertent dural puncture of LOR-A technique in epidural anesthesia is an uncommon but potentially fatal complication. Intracranial air accumulation in the brainstem could cause catastrophic complication. 6
ACCEPTED MANUSCRIPT Our experience provides a new insight for the use of HBOT in the management of
RI P
T
epidural procedure induced life-threatening pneumocephalus.
SC
LENGENDs
Figure 1 Cranial computed tomography showed intracranial air (arrow) accumulation
MA NU
in the subarachnoid space of skull base, including suprasellar and peripontine cistern
Table 1 Summary of reported severe complications caused by epidural injection or
AC
CE
PT
ED
anesthesia induced pneumocephalus
7
ACCEPTED MANUSCRIPT
PT
Table 1 Summary of reported severe complications caused by epidural injection or anesthesia associated pneumocephalus Age (Years)
Gender
Mechanism
Presentation
Present case
36
Female
LOR-A epidural
Cardiopulmonary Suprasellar and peripontine MVS;
Regain
anesthesia
arrest
consciousness after 3 hours
cervical epidural steroid injection
Cardiopulmonary Subarachnoid space from arrest C3 to C5 anteriorly, C3 down to C7 posteriorly, in
hyperbaric oxygen therapy MVS; therapeutic hypothermia
MVS
Discharge after uncertain days
MVS
Discharge after 5 days
NU S
MA
Female
CE P AC
cistern region
D
67
TE
Stauber, B., et al. (2012)[10]
Air distribution
CR I
Authors
Lin, H. Y., et al. (1997)[11]
82
Female
LOR-A epidural anesthesia
Respiratory depression
Sherer, D. M., et al. (1999)[12]
36
Female
LOR-A epidural anesthesia
Altered consciousness but spontaneous respiration
the prepontine cistern, subarachnoid space, and bilaterally in the frontal convexity Longitudinal cerebral sulci, lateral cerebral sulci, and the sylvian fissure Cistern of the lamina terminalis, the suprasellar cistern, pituitary fossa, and the subarachnoid spaces near the gyri recti
Treatment
Outcome
Regain consciousness after 48 hours
8
ACCEPTED MANUSCRIPT
25
Female
LOR-A epidural anesthesia
Altered consciousness but spontaneous respiration
Frontoparietal cerebral cortex region and suprasellar cistern
MVS
Regain consciousness after 24 hours
Chung, S. H., et
40
Female
epidural
severe
Sellar region, basal cistern
MVS
Discharge
anesthesia
headache and altered consciousness
CR I
NU S
and extra-axial space
after 15 days
MA
al. (2014)[14]
PT
Katz, Y., et al. (1990)[13]
AC
CE P
TE
D
Abbreviations: LOR-A, loss-of-resistance of air; MVS: mechanical ventilatory support
9
ACCEPTED MANUSCRIPT References
[5]. [6].
[7]. [8].
T
RI P
SC
Undersea Hyperb Med 2014; 41:151-7. Paiva WS, de Andrade AF, Figueiredo EG, Amorim RL, Prudente M, Teixeira MJ. Effects of hyperbaric oxygenation therapy on symptomatic pneumocephalus. Ther Clin Risk Manag 2014; 10:769-73. D'Agostino Dias MT, SV; Esteves, CH; Menegazzo, LM; Sousa, MR; Monteiro, JA; Bodon, LA. Pneumoencephalus: An unususal use for hyperbaric oxygentreatment. Undersea Hyperbaric Medicine 1997; 24(Suppl):p35, abstr 158. Stauber B, Ma L, Nazari R. Cardiopulmonary arrest following cervical
AC
[9].
Sweni S, Senthilkumaran S, Balamurugan N, Thirumalaikolundusubramanian P. Tension pneumocephalus: a case report with review of literature. Emerg Radiol 2013; 20:573-8. Schirmer CM, Heilman CB, Bhardwaj A. Pneumocephalus: case illustrations and review. Neurocrit Care 2010; 13:152-8. Prakash PS, Jain V, Sandhu K, Walia BS, Panigrahi BP. Brain stem tension pneumocephalus leading to respiratory distress after subdural haematoma evacuation. Eur J Anaesthesiol 2009; 26:795-7. Moon RE. Hyperbaric oxygen treatment for decompression sickness.
MA NU
[4].
ED
[3].
PT
[2].
Saberski LR, Kondamuri S, Osinubi OY. Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air. Reg Anesth 1997; 22:3-15. Aida S, Taga K, Yamakura T, Endoh H, Shimoji K. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology 1998; 88:76-81. Markham JW. The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases. Acta Neurochir (Wien) 1967; 16:1-78.
CE
[1].
[10]. [11].
[12].
[13].
epidural injection. Pain Physician 2012; 15:147-52. Lin HY, Wu HS, Peng TH, Yeh YJ, Cheng IC, Lin IS et al. Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report. Acta Anaesthesiol Sin 1997; 35:119-23. Sherer DM, Onyeije CI, Yun E. Pneumocephalus following inadvertent intrathecal puncture during epidural anesthesia: a case report and review of the literature. J Matern Fetal Med 1999; 8:138-40. Katz Y, Markovits R, Rosenberg B. Pneumoencephalos after inadvertent intrathecal air injection during epidural block. Anesthesiology 1990; 73:1277-9. 10
ACCEPTED MANUSCRIPT
CE
PT
ED
MA NU
SC
RI P
T
Chung SH, Kim TH, Lee HH. Change in mental status due to pneumocephalus after regional anaesthesia during obstetrics and gynaecological surgery. J Obstet Gynaecol 2014; 34:654-5.
AC
[14].
11
AC
CE
PT
ED
MA NU
SC
RI P
T
ACCEPTED MANUSCRIPT
12
S0735-6757(15)00046-7 doi: 10.1016/j.ajem.2015.01.044 YAJEM 54773
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
20 January 2015 23 January 2015
Please cite this article as: Shih Chang-Chih, Tsai Shih-Hung, Liao Wen-I, Wang JenChun, Hsu Chin-Wang, Successful treatment of epidural anesthesia induced severe pneumocephalus by hyperbaric oxygen therapy, American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.01.044
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Case report
T
Successful treatment of epidural anesthesia induced severe
Chang-Chih Shih, 2Shih-Hung Tsai, 2Wen-I Liao, 2Jen-Chun Wang, 1Chin-Wang Hsu*
Department
of
Emergency and
Critical
Care
Medicine,
Taipei
Medical
MA NU
1
SC
2
RI P
pneumocephalus by hyperbaric oxygen therapy
University-Wan Fang Hospital, Taipei, Taiwan 2
Department of Emergency Medicine, Tri-Service General Hospital, National Defense
ED
Medical Center, Taipei, Taiwan
PT
Financial support or interest: none *Corresponding to:
CE
Chin-Wang Hsu, M.D.,
Department of Emergency and Critical Care Medicine,
AC
Taipei Medical University-Wan Fang Hospital, Taipei No.111, Sec. 3, Hsing-Long Rd., Taipei 116, Taiwan Tel: +886-2-29307930; Fax: +886-2-2795-5682 E-mail: [email protected]
Keywords: pneumocephalus, epidural anesthesia, hyperbaric oxygen therapy
1
ACCEPTED MANUSCRIPT Abstract
T
Pneumocephalus is a rare complication after using loss-of-resistance to air (LOR-A)
RI P
technique of epidural anesthesia, and is usually caused by inadvertent dural
SC
puncture. Most patients with pneumocephalus have headache, motor weakness, seizures, and focal neurologic deficits depend on the distribution and amount of
MA NU
intracranial air. Consciousness decline and death had been reported due to mass effect or cerebral gas embolism. Either conservative treatment with 100% oxygen and ventilator support or surgical intervention with external ventricular drain had
ED
been reported as a treatment. We present a 36-year-old otherwise healthy woman
PT
with cardiopulmonary arrest and deep coma as a complication of LOR-A epidural
CE
anesthesia. She regained consciousness rapidly 3 hours after completion of
AC
one-session of 120 minutes emergent hyperbaric oxygen therapy (HBOT) at 2.8 atmospheres absolute pressure with 100% oxygen concentration. Our successful treatment provides a new insight for the use of HBOT in the management of epidural procedure induced life-threatening pneumocephalus.
2
ACCEPTED MANUSCRIPT Pneumocephalus after loss-of-resistance to air (LOR-A) technique of epidural
T
anesthesia is rare [1]. Headache and focal neurologic deficits may present very
RI P
depend on the distribution and amount of the intracranial air; but devastating
SC
complication could be developed. Here we report a patient who developed coma and cardiopulmonary arrest due to epidural anesthesia induced pneumocephalus. She
MA NU
recovered rapidly after treated with hyperbaric oxygen therapy (HBOT).
A 36-year-old otherwise healthy woman was transferred to our emergency
ED
department because of altered consciousness after the procedure of epidural
PT
anethesia. She had been scheduled for cystectomy for endometrioma of ovary at
CE
another gynecological clinic. She developed altered consciousness and
AC
cardiopulmonary arrest soon after the end of LOR-A technique-based epidural anesthesia procedure. Emergent endotracheal tube intubation and cardiopulmonary resuscitation were performed accordingly. On arrival, her blood pressure was 108/51 mmHg, pulse rate 102 beats/min, respiration rate 21 breaths/min, and body temperature 35.5℃. Neurological examinations revealed coma with a Glasgow Coma Scale three (Eyes one, Motor one, Verbal one, intubated) and absence of suction reflex and oculocephalic reflex, indicating dysfunction of brainstem. Cranial computed tomography (CT) without contrast enhancement showed an air 3
ACCEPTED MANUSCRIPT accumulation in the cerebrospinal fluid space of the skull base region anterior to the
T
brainstem (Figure 1). A diagnosis of severe pneumocephalus due to brainstem
RI P
compression was made. She regained consciousness rapidly 3 hours after completion
SC
of one-session of 120 minutes emergent hyperbaric oxygen therapy (HBOT) at 2.8 atmospheres absolute pressure with 100% oxygen concentration. She was extubated
retained neurological sequelae.
MA NU
13 hours after HBOT and discharged on the eighth hospital day in the absence of any
ED
To the best our knowledge, here we present for the first time that HBOT could rapidly
PT
ameliorate severe neurological deficit due to epidural anesthesia induced
CE
pneumocephalus. Pneumocephalus is defined as accumulation of air within the
AC
cranium, which is usually associated with trauma, neoplasm, infection and surgical intervention. Less than 3% of patients developed pneumocephalus after epidural anesthesia while using LOR-A technique [2]. This complication is usually caused by inadvertent dural puncture. Most patients with pneumocephalus had headache (40%), motor weakness (12%), seizures (8%), and acute delirium (5%) [3]. Nonetheless, altered consciousness and death had been reported due to mass effect or cerebral gas embolism [4, 5]. We reviewed and summarized the reported cases of epidural injection or anesthesia associated pneumocephalus with severe 4
ACCEPTED MANUSCRIPT complications, including loss of consciousness, cardiopulmonary arrest and death
T
(Table 1). Among these cases, the common etiologies were dural breach. All the
RI P
summarized cases were treated conservatively, including administration of 100%
SC
oxygen, fluid supplement and ventilation support, rather than surgical intervention. The duration of the recovery were more than 3 days in those patients. The severity of
MA NU
neurologic deficient is generally associated with the volume of the air and its mass effect. Nevertheless, it also related to the location and distribution of the intracranial air; even a small quantity of intracranial air collected in the limited space of the
ED
posterior fossa can cause significantly increased intracranial pressure, hence
PT
respiratory arrest [6]. The combination of deep coma in the absence of main
CE
brainstem reflex in the neurologic examination and pneumocephalus in the cisternal
AC
region anterior to the brainstem in the cranial CT supported that cardiopulmonary arrest followed by prolonged deep coma may be due to the compression of brainstem by the accumulated intracranial air in this patient. Conservative treatment for pneumocephalus is breathing 100% oxygen, which increases the rate of absorption of intracranial air [5]. Decompression with emergent craniotomy or evacuation of trapped air with external ventricular drain may be required for severe complications of pneumocephalus [6]. Notwithstanding, it is difficult and dangerous to aspirate the accumulated air surrounding to brainstem. HBOT is the main-stay-of 5
ACCEPTED MANUSCRIPT treatment for decompression sickness while bubble formation in tissues can result in
T
mechanical disruption of tissue, occlusion of blood flow, platelet activation,
RI P
endothelial dysfunction and capillary leakage [7]. According to Boyle's Law, the
SC
volume of nitrogen bubbles is inversely related to the pressure and dissolution is also accomplished by the replacement of oxygen [7]. HBOT is therefore putatively able to
MA NU
reduce air bubbles size in this case. Our experience was in line with a previous study regarding average of 8.8 exposures of HBOT at 2.5 atmospheres ameliorated headache and neurological deterioration due to pneumocephalus due to trauma or
ED
surgery in a selected group of 13 patients (excluded patients with endotracheal
PT
intubation or Glasgow Coma Scale scores less than 13 points) [8]. Another report also
CE
mentioned that in the patients with trauma or post-neurosurgery associated
AC
pneumocephalus, dramatic improvement in the neurologic symptoms, such as somnolence, mental confusion, paretic limbs, and acute pain could be achieved with 2 to 7 sessions of HBOT at 2.5 atmospheres[9]. Taken together, we believe that HBOT could have beneficial effects on the acute treatment of severe pneumocephalus.
In conclusion, pneumocephalus caused by inadvertent dural puncture of LOR-A technique in epidural anesthesia is an uncommon but potentially fatal complication. Intracranial air accumulation in the brainstem could cause catastrophic complication. 6
ACCEPTED MANUSCRIPT Our experience provides a new insight for the use of HBOT in the management of
RI P
T
epidural procedure induced life-threatening pneumocephalus.
SC
LENGENDs
Figure 1 Cranial computed tomography showed intracranial air (arrow) accumulation
MA NU
in the subarachnoid space of skull base, including suprasellar and peripontine cistern
Table 1 Summary of reported severe complications caused by epidural injection or
AC
CE
PT
ED
anesthesia induced pneumocephalus
7
ACCEPTED MANUSCRIPT
PT
Table 1 Summary of reported severe complications caused by epidural injection or anesthesia associated pneumocephalus Age (Years)
Gender
Mechanism
Presentation
Present case
36
Female
LOR-A epidural
Cardiopulmonary Suprasellar and peripontine MVS;
Regain
anesthesia
arrest
consciousness after 3 hours
cervical epidural steroid injection
Cardiopulmonary Subarachnoid space from arrest C3 to C5 anteriorly, C3 down to C7 posteriorly, in
hyperbaric oxygen therapy MVS; therapeutic hypothermia
MVS
Discharge after uncertain days
MVS
Discharge after 5 days
NU S
MA
Female
CE P AC
cistern region
D
67
TE
Stauber, B., et al. (2012)[10]
Air distribution
CR I
Authors
Lin, H. Y., et al. (1997)[11]
82
Female
LOR-A epidural anesthesia
Respiratory depression
Sherer, D. M., et al. (1999)[12]
36
Female
LOR-A epidural anesthesia
Altered consciousness but spontaneous respiration
the prepontine cistern, subarachnoid space, and bilaterally in the frontal convexity Longitudinal cerebral sulci, lateral cerebral sulci, and the sylvian fissure Cistern of the lamina terminalis, the suprasellar cistern, pituitary fossa, and the subarachnoid spaces near the gyri recti
Treatment
Outcome
Regain consciousness after 48 hours
8
ACCEPTED MANUSCRIPT
25
Female
LOR-A epidural anesthesia
Altered consciousness but spontaneous respiration
Frontoparietal cerebral cortex region and suprasellar cistern
MVS
Regain consciousness after 24 hours
Chung, S. H., et
40
Female
epidural
severe
Sellar region, basal cistern
MVS
Discharge
anesthesia
headache and altered consciousness
CR I
NU S
and extra-axial space
after 15 days
MA
al. (2014)[14]
PT
Katz, Y., et al. (1990)[13]
AC
CE P
TE
D
Abbreviations: LOR-A, loss-of-resistance of air; MVS: mechanical ventilatory support
9
ACCEPTED MANUSCRIPT References
[5]. [6].
[7]. [8].
T
RI P
SC
Undersea Hyperb Med 2014; 41:151-7. Paiva WS, de Andrade AF, Figueiredo EG, Amorim RL, Prudente M, Teixeira MJ. Effects of hyperbaric oxygenation therapy on symptomatic pneumocephalus. Ther Clin Risk Manag 2014; 10:769-73. D'Agostino Dias MT, SV; Esteves, CH; Menegazzo, LM; Sousa, MR; Monteiro, JA; Bodon, LA. Pneumoencephalus: An unususal use for hyperbaric oxygentreatment. Undersea Hyperbaric Medicine 1997; 24(Suppl):p35, abstr 158. Stauber B, Ma L, Nazari R. Cardiopulmonary arrest following cervical
AC
[9].
Sweni S, Senthilkumaran S, Balamurugan N, Thirumalaikolundusubramanian P. Tension pneumocephalus: a case report with review of literature. Emerg Radiol 2013; 20:573-8. Schirmer CM, Heilman CB, Bhardwaj A. Pneumocephalus: case illustrations and review. Neurocrit Care 2010; 13:152-8. Prakash PS, Jain V, Sandhu K, Walia BS, Panigrahi BP. Brain stem tension pneumocephalus leading to respiratory distress after subdural haematoma evacuation. Eur J Anaesthesiol 2009; 26:795-7. Moon RE. Hyperbaric oxygen treatment for decompression sickness.
MA NU
[4].
ED
[3].
PT
[2].
Saberski LR, Kondamuri S, Osinubi OY. Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air. Reg Anesth 1997; 22:3-15. Aida S, Taga K, Yamakura T, Endoh H, Shimoji K. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology 1998; 88:76-81. Markham JW. The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases. Acta Neurochir (Wien) 1967; 16:1-78.
CE
[1].
[10]. [11].
[12].
[13].
epidural injection. Pain Physician 2012; 15:147-52. Lin HY, Wu HS, Peng TH, Yeh YJ, Cheng IC, Lin IS et al. Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report. Acta Anaesthesiol Sin 1997; 35:119-23. Sherer DM, Onyeije CI, Yun E. Pneumocephalus following inadvertent intrathecal puncture during epidural anesthesia: a case report and review of the literature. J Matern Fetal Med 1999; 8:138-40. Katz Y, Markovits R, Rosenberg B. Pneumoencephalos after inadvertent intrathecal air injection during epidural block. Anesthesiology 1990; 73:1277-9. 10
ACCEPTED MANUSCRIPT
CE
PT
ED
MA NU
SC
RI P
T
Chung SH, Kim TH, Lee HH. Change in mental status due to pneumocephalus after regional anaesthesia during obstetrics and gynaecological surgery. J Obstet Gynaecol 2014; 34:654-5.
AC
[14].
11
AC
CE
PT
ED
MA NU
SC
RI P
T
ACCEPTED MANUSCRIPT
12