Tension pneumocephalus following endoscopic resection of a mediastinal thoracic spinal tumor: A case report

Abstract

Background: Pneumocephalus is a rare complication presenting in the postoperative period of a thoracoscopic operation. We report a case in which tension pneumocephalus occurred after thoracoscopic resection as well as the subsequent approach of surgical management.

Case summary: A 66-year-old man who received thoracoscopic resection to remove an intrathoracic, posterior mediastinal, dumbbell-shaped, pathology-proven neurogenic tumor. The patient then reported experiencing progressively severe headaches, especially when in an upright position. A brain computed tomography scan at a local hospital disclosed extensive pneumocephalus. Revision surgery for resection of the pseudomeningocele and repair of the cerebrospinal fluid leakage was thus arranged for the patient. During the operation, we traced the cerebrospinal fluid leakage and found that it might have derived from incomplete endoscopic clipping around the tumor stump near the dural sac at the T3 level. After that, we wrapped and sealed all the possible origins of the leakage with autologous fat, tissue glue, gelfoam, and duraseal layer by layer. The patient recovered well, and the computed tomography images showed resolution of the pneumocephalus.

Conclusion: This report and literature review indicated that the risk of developing a tension pneumocephalus cannot be ignored and should be monitored carefully after thoracoscopic tumor resection.

Keywords: Case report; Neurogenic tumor; Tension pneumocephalus; Thoracoscope.

Figure 1

Computed tomography scans of the patient’s brain showing tension pneumocephalus. A: Non-contrast views of preoperative brain computed tomography images; B-C: Images of axial (B) and sagittal view (C) show progressive tension pneumocephalus, pneumoventricle, and air leak in the spinal canal.

Figure 2

Pre-operative evaluations. A-B: T2-weighted magnetic resonance imaging in axial view (A) and fast spin echo, fat-suppression coronal view (B) showing a cystic pouch laterally surrounding the spinal nerve root at left T3 level (arrow), which may be derived from the neural foramen of the L3 level. The air-fluid level was also demonstrated (arrow); C) Axial view of chest computed tomography showing pneumothorax and subcutaneous emphysema (arrow); D) Poorly healing previous thoracoscopic access wound.

Figure 3

Histological examination of the spinal tumor. A: Intraoperative image of the posterior mediastinal tumor demonstrated well-defined border, which was pathologically proved to be neurogenic tumor; B-F: A histological image of the neurofibroma showing bland spindle cells with wavy nuclei and pale eosinophilic cytoplasm (scale bar 50 μm) (B), secondary degeneration of hyalinization (scale bar 200 μm) (C), calcification (scale bar 100 μm) (D), cyst (scale bar 500 μm) (E), and hemorrhage (scale bar 200 μm) (F).

Figure 4

Intraoperative images of the surgical repair. A: Cerebrospinal fluid leakage might derive from the previous endoscopic clipped tumor stump near the dural sac of the T3 level (arrow); B-C: Repairing of the leakage sites with tissue glue, gelfoam, and dural seal.

Figure 5

Post-operative computed tomography images demonstrate successful repair. A-B: Axial view of brain computed tomography on the 5th (A) and 15th postoperative day (B) showing resolution of pneumocephalus and pneumoventricle though subdural effusion accumulation without brain parenchymal compression.