Traumatic tension pneumocephalus - Two cases and comprehensive review of literature

Abstract

Although traumatic pneumocephalus is not uncommon, it rarely evolves into tension pneumocephalus (TP). Characterized by the presence of increasing amounts of intracranial air and concurrent appearance or worsening neurological symptoms, TP can be devastating if not recognized and treated promptly. We present two cases of traumatic TP and a concise review of literature on this topic. Two cases of traumatic TP are presented. In addition, a literature search revealed 20 additional cases, of which 18 had sufficient information for inclusion. Literature cases were combined with the 2 reported cases and analyzed for demographics, mechanism of injury, symptoms, time to presentation (acute <72 h; delayed >72 h), diagnostic/treatment modalities, and outcomes. Twenty cases were analyzed (17 males, 3 females, median age 26, range 8-92 years). Presentation was acute in 13/20 and delayed in 7/20 patients. Injury mechanisms included motor vehicle collisions (6/20), assault/blunt trauma to the craniofacial area (5), falls (4), and motorcycle/ bicycle crashes (3). Common presentations included depressed mental status (10/20), cerebrospinal fluid rhinorrhea (9), headache (8), and loss of consciousness (6). Computed tomography (CT) was utilized in 19/20 patients. Common underlying injuries were frontal bone/sinus fracture (9/20) and ethmoid fracture (5). Intracranial hemorrhage was seen in 5/20 patients and brain contusions in 4/20 patients. Nonoperative management was utilized in 6/20 patients. Procedural approaches included craniotomy (11/20), emergency burr hole (4), endoscopy (2), and ventriculostomy (2). Most patients responded to initial treatment (19/20). One early and one delayed death were reported. Traumatic TP is rare, tends to be associated with severe craniofacial injuries, and can occur following both blunt and penetrating injury. Early recognition and high index of clinical suspicion are important. Appropriate treatment results in improvement in vast majority of cases. CT scan is the diagnostic modality of choice for TP.

Republished with permission from: Pillai P, Sharma R, MacKenzie L, Reilly EF, Beery II PR, Papadimos TJ, Stawicki SPA. Traumatic tension pneumocephalus: Two cases and comprehensive review of literature. OPUS 12 Scientist 2010;4(1):6-11.

Keywords: Cerebrospinal fluid leak; Glasgow Coma Scale; computed tomography scan; craniofacial trauma; head injury; pneumocephalus; tension pneumocephalus.

Figure 1

Computed tomographic imaging for Case 1: (a-b) admission computed tomography shows small foci of pneumocephalus; (c-d) admission images showing associated skull fractures, including right mastoid process fracture; (e-f) repeat computed tomographic imaging shows the appearance of the “Mount Fuji” sign

Figure 2

Computed tomographic imaging for Case 2: (a) initial computed tomography – note the presence of small amounts of intracranial air; (b and c) repeat computed tomography of the brain demonstrating increasing pneumocephalus, with slight midline shift (c) and “Mount Fuji” sign; and (d) postoperative computed tomography showing the resolution of tension pneumocephalus