Outcome of Posttraumatic Delayed Intracerebral Tension Pneumatocele: Prospective Study of Four Cases: Single Institutional Experience

Abstract

Aim: Delayed intracerebral tension pneumatocele (DITP) is an uncommon cause of raised intracranial pressure following trauma. However, it can cause herniation syndrome due to a sudden increase in intracranial pressure which requires emergent intervention. Pneumocephalus is a complication of head injury in 3.9%-9.7% of the cases. The accumulation of intracranial air can be acute (<72 h) or delayed (≥72 h).

Method: When intracranial air causes intracranial hypertension and has a mass effect with neurological deterioration, it is called tension pneumocephalus. In our case series, we demonstrated four cases of DITP in adult patients from January 2012 to January 2017 in the Department of Neurosurgery at R. N. T. Medical College and M. B. Hospital, Udaipur, Rajasthan.

Result: During this period, a total number of patients admitted of head injury are 1768 and hence, the incidence of DITP in our series is 0.226% which is very less as compared to previous literature. All patients are male; age ranging from 17 years to 55 years (mean age was 31.75 years). All patients have a history of head injury, and mode of injury had road traffic accidents. Glasgow Coma Score (GCS) at readmission were 12-13 (mean GCS 12.75). Duration of developed DITP 1 month to 2½ months (mean 1.375 months), all patients had gone to surgical intervention, and outcome assessed using Glasgow outcome score. All patients had a good outcome and average follow-up was 12.5 months.

Conclusion: long term observation of patients with simple pneumocephalus following trauma is beneficial as there is an expected risk of developing delayed tension pneumocephalus which may manifest with raised intracranial pressure.

Keywords: Cerebrospinal fluid rhinorrhea; intracerebral; pneumocephalus; tension pneumatocele.

Figure 1

(a) Noncontrast computed tomography Head revealed fracture of Left frontal bone involving the sinus with depression of posterior wall of the sinus, underlying multiple contusions of frontal lobe and no pneumocephalus. (b) Magnetic resonance imaging T2 W image revealed a large Left frontal intraparenchymal tension pneumatocele causing mass effect. (c) noncontrast computed tomography Head revealed minimal Left Frontal pneumatocele with no mass effect

Figure 2

(a) A noncontrast computed tomography Head revealed bilateral frontal contusion with fracture of bilateral frontal bone with involving the right frontal sinus with mild depression of posterior wall of sinus with Mild pneumocephalus. (b) Repeat noncontrast computed tomography Head revealed tension intraparenchymal pneumatocele on right frontal lobe with mass effect and communicating with bilateral lateral ventricles, basal cisterns and subarachnoid spaces. (c) On postoperative noncontrast computed tomography scans revealed resorption of frontal pneumatocele with minimal subarachnoid and intraventricular air; there was a minimal residual Pneumocephalus

Figure 3

(a) Fracture of Left frontal bone involving the sinus with mild depression of posterior wall of the sinus, underlying tiny contusions of left frontal lobe and Bilateral pneumocephalus in baso-frontal convexity extending to interhemispheric fissure which was not significant and no mass effect. (b) Large Left frontal intraparenchymal tension pneumatocele causing mass effect. (c) Minimal Left Frontal pneumatocele with no mass effect

Figure 4

(a) Fracture of Left frontal bone involving the sinus, underlying tiny contusions of bilateral frontal lobe and bilateral pneumocephalus in baso-frontal convexity extending to interhemispheric fissure which was not significant and no mass effect. (b) Magnetic resonance imaging fluid-attenuated inversion recovery image revealed large left frontal intraparenchymal tension pneumatocele causing mass effect. (c) Minimal left frontal pneumatocele with no mass effect