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Journal of Neurosurgery. Case Lessons Sep 2023Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal...
BACKGROUND
Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory.
OBSERVATIONS
A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula.
LESSONS
Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.
PubMed: 37728168
DOI: 10.3171/CASE23300 -
Indian Journal of Otolaryngology and... Sep 2023While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal...
While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications.
PubMed: 37636702
DOI: 10.1007/s12070-023-03802-5 -
Cureus Dec 2023A subdural hematoma (SDH) is a medical condition caused by a violent head trauma in which blood accumulates excessively under the dura mater. It occurs when a blood...
Early Mobilization and Rehabilitation to Enhance the Functional Performance of a Hemiparesis Patient Following a Subdural and Subarachnoid Hematoma With Pneumocephalus: A Case Report.
A subdural hematoma (SDH) is a medical condition caused by a violent head trauma in which blood accumulates excessively under the dura mater. It occurs when a blood arterial weak point or brain surface aneurysm ruptures and bleeds. The resulting blood accumulation inside and around the skull raises the pressure on the brain. Pneumocephalus, also known as pneumatocele or intracranial aerogel, refers to air in the ventricular cavities or brain parenchyma's epidural, subdural, or subarachnoid spaces. In most cases, neurotrauma is the primary cause of pneumocephalus, mainly when there are skull base fractures. Here, we present a case study of a 65-year-old male patient diagnosed with left hemiplegia following SDH with subarachnoid hematoma (SAH) and pneumocephalus. The severity of the patient's illness, the medical and surgical care provided, the amount of physiotherapy required to aid recovery, the duration of hospitalization, and the discharge location for patients with acute SAH or SDH vary significantly. The patient underwent physiotherapy rehabilitation, and we report that his lower limb strength improved substantially after the therapy. Therefore, physiotherapy is a critical component of treatment to enhance muscle strength, facilitate early and rapid recovery, and manage the clinical manifestations of the condition.
PubMed: 38288164
DOI: 10.7759/cureus.51199 -
World Neurosurgery May 2024Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We... (Comparative Study)
Comparative Study
OBJECTIVES
Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We hypothesized that effective and timely drainage of subdural space may improve clinical and radiological outcomes. This study was conducted to compare the effectiveness of standard closed drainage and underwater drainage.
METHODS
Medical data of 300 surgically treated chronic subdural hematoma CDH patients were retrospectively collected and analyzed. The patients were divided into two 2 groups: Group I with underwater drainage, and Group II with closed drainage. Groups were compared in terms of gender, age, complication rates, recurrence rates, seizure rates, and length of hospital stay.
RESULTS
Underwater drainage was found superior to closed system by all clinical and radiographic parameters. The recurrence rate was significantly lower in Group I (2%) compared to with Group II (10%). Subdural empyema was observed in 10 patients in Group II and none in Group I. The seizure rate was higher in Group II (18%) compared to with Group I (5%). Postoperative pneumocephalus rates was were 20% in Group I and 54% in Group II. The length of hospital stay was 6±2.6 days in Group I and 8.9±6.1 days in Group II. The length of intensive care unit (ICU) stay was 0.6±1.12 days in Group I and 2.7±5 days in Group II. A minority (5%) of the patients in Group II required reoperation due to recurrence.
CONCLUSIONS
The use of underwater system significantly the reduces the rates of pneumocephalus, seizures, infection, and recurrence. Additional benefits are shorter intensive care unit ICU and total hospital stays.
Topics: Humans; Hematoma, Subdural, Chronic; Male; Female; Drainage; Middle Aged; Retrospective Studies; Aged; Treatment Outcome; Adult; Length of Stay; Postoperative Complications; Neurosurgical Procedures; Aged, 80 and over
PubMed: 38479641
DOI: 10.1016/j.wneu.2024.03.004 -
Neurocritical Care Jun 2024Intracranial multimodal monitoring (iMMM) is increasingly used for neurocritical care. However, concerns arise regarding iMMM invasiveness considering limited evidence... (Meta-Analysis)
Meta-Analysis Review
Intracranial multimodal monitoring (iMMM) is increasingly used for neurocritical care. However, concerns arise regarding iMMM invasiveness considering limited evidence in its clinical significance and safety profile. We conducted a synthesis of evidence regarding complications associated with iMMM to delineate its safety profile. We performed a systematic review and meta-analysis (PROSPERO Registration Number: CRD42021225951) according to the Preferred Reporting Items for Systematic Review and Meta-Analysis and Peer Review of Electronic Search Strategies guidelines to retrieve evidence from studies reporting iMMM use in humans that mention related complications. We assessed risk of bias using the Newcastle-Ottawa Scale and funnel plots. The primary outcomes were iMMM complications. The secondary outcomes were putative risk factors. Of the 366 screened articles, 60 met the initial criteria and were further assessed by full-text reading. We included 22 studies involving 1206 patients and 1434 iMMM placements. Most investigators used a bolt system (85.9%) and a three-lumen device (68.8%), mainly inserting iMMM into the most injured hemisphere (77.9%). A total of 54 postoperative intracranial hemorrhages (pooled rate of 4%; 95% confidence interval [CI] 0-10%; I 86%, p < 0.01 [random-effects model]) was reported, along with 46 misplacements (pooled rate of 6%; 95% CI 1-12%; I 78%, p < 0.01) and 16 central nervous system infections (pooled rate of 0.43%; 95% CI 0-2%; I 64%, p < 0.01). We found 6 system breakings, 18 intracranial bone fragments, and 5 cases of pneumocephalus. Currently, iMMM systems present a similar safety profile as intracranial devices commonly used in neurocritical care. Long-term outcomes of prospective studies will complete the benefit-risk assessment of iMMM in neurocritical care. Consensus-based reporting guidelines on iMMM use are needed to bolster future collaborative efforts.
Topics: Humans; Critical Care; Neurophysiological Monitoring; Intracranial Hemorrhages; Postoperative Complications
PubMed: 37991675
DOI: 10.1007/s12028-023-01885-0 -
Dynamic Lateral Semisitting Position for Supracerebellar Approaches: Technical Note and Case Series.Operative Neurosurgery (Hagerstown, Md.) Aug 2023It has always been a matter of debate which position is ideal for the supracerebellar approach. The risk of venous air embolism (VAE) is the major deterrent for surgeons...
BACKGROUND
It has always been a matter of debate which position is ideal for the supracerebellar approach. The risk of venous air embolism (VAE) is the major deterrent for surgeons and anesthesiologists, despite the fact that sitting and semisitting positions are commonly used in these operations.
OBJECTIVE
To demonstrate a reduction on the risk of VAE and tension pneumocephalus throughout the operation period while taking advantages of the semisitting position.
METHODS
In this study, 11 patients with various diagnoses were operated in our department using the supracerebellar approach in the dynamic lateral semisitting position. We used end-tidal carbon dioxide and arterial blood pressure monitoring to detect venous air embolism.
RESULTS
None of the patients had clinically significant VAE in this study. No tension pneumocephalus or major complications were observed. All the patients were extubated safely after surgery.
CONCLUSION
The ideal position, with which to apply the supracerebellar approach, is still a challenge. In our study, we presented an alternative position that has advantages of the sitting and semisitting positions with a lower risk of venous air embolism.
Topics: Humans; Patient Positioning; Neurosurgical Procedures; Embolism, Air; Pneumocephalus; Sitting Position
PubMed: 37255298
DOI: 10.1227/ons.0000000000000758 -
Annals of the Royal College of Surgeons... Jul 2024Tension pneumocephalus (TP) after spinal surgery is very rare with only a few cases reported in the English literature. Most cases of TP occur rapidly after spinal...
Tension pneumocephalus (TP) after spinal surgery is very rare with only a few cases reported in the English literature. Most cases of TP occur rapidly after spinal surgery. Traditionally, TP is managed using burr holes to relieve intracranial pressure. However, our case highlights a rare delayed presentation of TP and pneumorrhacis 1 month after routine cervical spine surgery. It is to our knowledge the first case of TP after spinal surgery to be treated using dural repair and supportive care. A 75-year-old woman presented with TP after having routine cervical decompression and stabilisation for cervical myelopathy. She re-presented 1 month after her initial operation with a leaking wound and altered mental status, which deteriorated rapidly shortly after admission. This, in combination with her radiographic features, influenced the decision to explore her surgical wound emergently. She made a full recovery and was discharged after 2 weeks in hospital. We hope to emphasise the need for a high index of suspicion for cerebrospinal fluid leaks and the low threshold to return to theatre to repair a potential dural defect, as well as illustrate that TP after spinal surgery can be treated successfully without burr holes.
Topics: Humans; Pneumocephalus; Female; Aged; Cervical Vertebrae; Decompression, Surgical; Postoperative Complications; Pneumorrhachis; Tomography, X-Ray Computed
PubMed: 37381753
DOI: 10.1308/rcsann.2023.0037 -
Journal of Neurosurgery. Case Lessons Dec 2023Epidermoid cyst tumors can arise as intradiploic tumors in the frontal skull bones around the fontanel in childhood but are mostly found at the frontal or frontotemporal...
BACKGROUND
Epidermoid cyst tumors can arise as intradiploic tumors in the frontal skull bones around the fontanel in childhood but are mostly found at the frontal or frontotemporal base of the brain or in the cerebellopontine angle. Therefore, finding a symptomatic intradiploic lesion in the convexity in late adulthood is uncommon. Intradiploic epidermoids can cause complications as they grow, by eroding and perforating their surroundings, and in cases of destruction of the wall of a pneumatized sinus, they can cause pneumocephalus.
OBSERVATIONS
In the present case, a female patient presented with a skull lesion that had grown progressively over 64 years, resulting in spontaneous pneumocephalus. Surgery with subsequent cranioplasty was performed. The histological examination confirmed the presence of an intradiploic epidermoid.
LESSONS
This case highlights that complete resection of the lesion with subsequent cranioplasty is recommended before symptoms and reconstructive challenges due to the enormous size of the defect. This case serves as a reminder that intradiploic epidermoids, although uncommon, will expand throughout life and can cause significant complications such as pneumocephalus after decades. Timely surgical interventions after diagnosis are recommended to prevent further complications and to achieve a successful outcome in terms of complete resection and reconstruction.
PubMed: 38109733
DOI: 10.3171/CASE23614 -
Stereotactic and Functional Neurosurgery 2024Deep brain stimulation (DBS) is a routine neurosurgical procedure utilized to treat various movement disorders including Parkinson's disease (PD), essential tremor (ET),...
INTRODUCTION
Deep brain stimulation (DBS) is a routine neurosurgical procedure utilized to treat various movement disorders including Parkinson's disease (PD), essential tremor (ET), and dystonia. Treatment efficacy is dependent on stereotactic accuracy of lead placement into the deep brain target of interest. However, brain shift attributed to pneumocephalus can introduce unpredictable inaccuracies during DBS lead placement. This study aimed to determine whether intracranial air is associated with brain shift in patients undergoing staged DBS surgery.
METHODS
We retrospectively evaluated 46 patients who underwent staged DBS surgery for PD, ET, and dystonia. Due to the staged nature of DBS surgery at our institution, the first electrode placement is used as a concrete fiducial marker for movement in the target location. Postoperative computed tomography (CT) images after the first electrode implantation, as well as preoperative, and postoperative CT images after the second electrode implantation were collected. Images were analyzed in stereotactic targeting software (BrainLab); intracranial air was manually segmented, and electrode shift was measured in the x, y, and z plane, as well as a Euclidian distance on each set of merged CT scans. A Pearson correlation analysis was used to determine the relationship between intracranial air and brain shift, and student's t test was used to compare means between patients with and without radiographic evidence of intracranial air.
RESULTS
Thirty-six patients had pneumocephalus after the first electrode implantation, while 35 had pneumocephalus after the second electrode implantation. Accumulation of intracranial air following the first electrode implantation (4.49 ± 6.05 cm3) was significantly correlated with brain shift along the y axis (0.04 ± 0.35 mm; r (34) = 0.36; p = 0.03), as well as the Euclidean distance of deviation (0.57 ± 0.33 mm; r (34) = 0.33; p = 0.05) indicating statistically significant shift on the ipsilateral side. However, there was no significant correlation between intracranial air and brain shift following the second electrode implantation, suggesting contralateral shift is minimal. Furthermore, there was no significant difference in brain shift between patients with and without radiographic evidence of intracranial air following both electrode implantation surgeries.
CONCLUSION
Despite observing volumes as high as 22.0 cm3 in patients with radiographic evidence of pneumocephalus, there was no significant difference in brain shift when compared to patients without pneumocephalus. Furthermore, the mean magnitude of brain shift was <1.0 mm regardless of whether pneumocephalus was presenting, suggesting that intracranial air accumulation may not produce clinical significant brain shift in our patients.
Topics: Humans; Deep Brain Stimulation; Dystonia; Retrospective Studies; Pneumocephalus; Magnetic Resonance Imaging; Electrodes, Implanted; Brain; Parkinson Disease; Essential Tremor; Dystonic Disorders
PubMed: 38286119
DOI: 10.1159/000535197 -
Neurology Mar 2024
Topics: Humans; Meningioma; Pneumocephalus; Postoperative Complications; Meningeal Neoplasms
PubMed: 38330284
DOI: 10.1212/WNL.0000000000209185