Extensive tension pneumocephalus caused by spinal tapping in a patient with Basal skull fracture and pneumothorax

Abstract

Tension pneumocephalus may follow a cerebrospinal fluid (CSF) leak communicating with extensive extradural air. However, it rarely occurs after diagnostic lumbar puncture, and its treatment and pathophysiology are uncertain. Tension pneumocephalus can develop even after diagnostic lumbar puncture in a special condition. This extremely rare condition and underlying pathophysiology will be presented and discussed. The authors report the case of a 44-year-old man with a basal skull fracture accompanied by pneumothorax necessitating chest tube suction drainage, who underwent an uneventful lumbar tapping that was complicated by postprocedural tension pneumocephalus resulting in an altered mental status. The patient was managed by burr hole trephination and saline infusion following chest tube disengagement. He recovered well with no neurologic deficits after the operation, and a follow-up computed tomography (CT) scan demonstrated that the pneumocephalus had completely resolved. Tension pneumocephalus is a rare but serious complication of lumbar puncture in patients with basal skull fractures accompanied by pneumothorax, which requires continuous chest tube drainage. Thus, when there is a need for lumbar tapping in these patients, it should be performed after the negative pressure is disengaged.

Keywords: Pneumocephalus; Pneumothorax; Spinal tapping.

Fig. 1

Computed tomography (CT) scan obtained at admission in a 45-year-old man with a basal skull fracture and pneumothorax. A : Axial CT scan showing a punctuate focus of air around the frontal crest (arrow). B : Coronal facial bone CT scan demonstrating fractures in the right orbital wall and the frontal sinus (arrowheads). C : Chest CT scan revealing extensive pneumothorax and intramuscular emphysema in the left chest wall (arrowhead).

Fig. 2

A : Computed tomography (CT) scans obtained 3 days after a diagnostic spinal tap showing extensive intraventricular, intracerebral, subdural, and cisternal pneumocephalus causing tension in the brain. B : Post-operative CT scan demonstrating that cisterns and ventricles are filled with saline to a certain extent, thus relieving the intracranial pressure. C : Follow-up CT scan obtained 6 weeks after surgery showing normal ventricles and cisterns.

Fig. 3

Schematic drawings showing the mechanism of extensive pneumocephalus caused by negative pressure. A : Schematic drawing of the normal status of the body. B : When negative pressure is applied, the spinal epidural space expands, and the subdural space is distended, leading to a decrease in the intracranial pressure. C : In the presence of cerebrospinal fluid (CSF) fistulae, air may be drawn into the subdural space. If spinal tapping is attempted, CSF may leak continuously, and extensive pneumocephalus may finally occur.