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Case Reports
. 2025 Jan 28;17(1):e78123.
doi: 10.7759/cureus.78123. eCollection 2025 Jan.

Atypical Presentation of Pneumocephalus Post Ventriculoperitoneal Shunt in a Patient With a History of Endoscopic Endonasal Skull Base Approach: A Case Report

Rahaf M Alalawi  1 , Waseem Th Alharthi  1 , Reem F Almaimani  2 , Abdulaziz A Almusa  3
Affiliations
Case Reports

Atypical Presentation of Pneumocephalus Post Ventriculoperitoneal Shunt in a Patient With a History of Endoscopic Endonasal Skull Base Approach: A Case Report

Rahaf M Alalawi et al. Cureus. .

Abstract

Pneumocephalus, commonly seen after trauma, surgical intervention, or meningitis, is rarely associated with ventriculoperitoneal shunt (VPS) procedures. We present a unique case of tension pneumocephalus in a 26-year-old female who experienced two distinct episodes of pneumocephalus. She presented with right-sided facial numbness, hearing loss, blurry vision, and gait disturbance. Magnetic resonance imaging (MRI) revealed a large extra-axial lesion at the right petrous apex extending to the middle cranial fossa. The patient underwent an extended endoscopic endonasal approach for tumor resection, and the pathological diagnosis revealed an epidermoid cyst. Postoperatively, she improved. However, she developed abducens nerve palsy followed by extensive pneumocephalus with intraventricular extension, necessitating skull base defect repair. Six weeks later, she presented with acute hydrocephalus secondary to meningitis from Klebsiella pneumoniae, confirmed by positive cerebrospinal fluid (CSF) cultures. She was treated with external ventricular drainage and antibiotic therapy, after which a VPS was inserted. Three days post-shunt insertion, the patient developed left-sided hemiparesis and swallowing dysfunction due to localized pneumocephalus within the tumor cavity compressing the brainstem. Following additional surgical intervention, her hemiparesis and other symptoms resolved. This case highlights the potential for tension pneumocephalus following ventriculoperitoneal shunt insertion for hydrocephalus. The siphon effects of CSF shunting can cause excessively negative intracranial pressure. Combined with a postoperative skull base defect, this can lead to air ingress through the defect (ball valve mechanism), causing pneumocephalus.

Keywords: csf leak; endoscopic endonasal; epidermoid cyst; hydrocephalous; tension pneumocephalus.

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Axial MRI and diffusion-weighted imaging (DWI) of a hyperintense extra-axial lesion at the right petrous apex
(A) T2-weighted MRI shows a hyperintense lesion at the right petrous apex with a mass effect on surrounding structures. (B) The ADC (apparent diffusion coefficient) map shows restricted diffusion within the lesion, indicative of high cellularity. (C) T2-weighted MRI highlights the lesion’s extension into the middle cranial fossa, further compressing adjacent areas. (D) DWI confirms restricted diffusion within the lesion, supporting the diagnosis of a tumor.
Figure 2
Figure 2. CT brain indicating extensive pneumocephalus five days after initial tumor resection
Figure 3
Figure 3. MRI imaging demonstrating localized pneumocephalus within the tumor cavity
Figure 4
Figure 4. CT imaging demonstrating localized pneumocephalus within the tumor cavity
Figure 5
Figure 5. Plain CT brain post-repair, demonstrating resolution of pneumocephalus following endoscopic repair
See this image and copyright information in PMC

References

    1. Traumatic tension pneumocephalus: two case reports. Al-Aieb A, Peralta R, Ellabib M, El-Menyar A, Al-Thani H. https://doi.org/10.1016/j.ijscr.2017.01.038. Int J Surg Case Rep. 2017;31:145–149. - PMC - PubMed
    1. Pneumocephalus as a rare complication: a systematic review plus clinical vignette. Śmiłowska K, Sznajder-Stacha K, Kocyłowski D, Popek A, Rozpondek K, Grechuta M, Salari M. https://doi.org/10.5603/PJNNS.a2021.0014. Neurol Neurochir Pol. 2021;55:253–268. - PubMed
    1. An unusual presentation of frontal bony defect with pneumocephalus and its management in an elderly patient. Chen ST, Lin HC, Huang JK, Wank YP. https://www.researchgate.net/publication/273389070_An_Unusual_Presentati... Int J Gerontol. 2015;9:54–56.
    1. Posttraumatic delayed subdural tension pneumocephalus. Solomiichuk VO, Lebed VO, Drizhdov KI. Surg Neurol Int. 2013;4:37. - PMC - PubMed
    1. Intraventricular pneumocephalus as a complication of ventriculoperitoneal shunt. da Silva AJ, Malta Doria AL. Cureus. 2021;13:0. - PMC - PubMed

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