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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 4  |  Page : 459-460

Endoscopic cure for post-traumatic pneumocephalus: When air hits the brain, treatment may not be the same


1 Department of Neurosurgery, Mahatma Gandhi Memorial Medical College and Hospital, Aurangabad, Maharashtra, India
2 Department of Otolaryngology, Mahatma Gandhi Memorial Medical College and Hospital, Aurangabad, Maharashtra, India

Date of Web Publication19-Sep-2014

Correspondence Address:
Sameer Shankar Futane
Department of Neurosurgery, Mahatma Gandhi Memorial Medical College and Hospital, Aurangabad, Maharashtra
India
Sameer Shankar Futane
Department of Neurosurgery, Mahatma Gandhi Memorial Medical College and Hospital, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.141274

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How to cite this article:
Ansari I, Futane SS, Ansari A, Ansari I, Futane SS, Ansari A. Endoscopic cure for post-traumatic pneumocephalus: When air hits the brain, treatment may not be the same . Neurol India 2014;62:459-60

How to cite this URL:
Ansari I, Futane SS, Ansari A, Ansari I, Futane SS, Ansari A. Endoscopic cure for post-traumatic pneumocephalus: When air hits the brain, treatment may not be the same . Neurol India [serial online] 2014 [cited 2019 Aug 21];62:459-60. Available from: http://www.neurologyindia.com/text.asp?2014/62/4/459/141274


Sir,

The causes and management of tension pneumocephalus have been well discussed. [1] Skull base endoscopy is also an often cited cause of pneumocephalus. [2] Herein, we describe an innovative way of treatment of post-traumatic pneumocephalus using endoscopic frontal sinus packing.

A 23-year-old man presented with recent onset left side progressive hemiparesis following a head injury three months back. Neurologic examination revealed left hemiparesis with motor power of 3/5. There was no cerebrospinal fluid (CSF) rhinorrhea. Computer tomography (CT) scans done at the time of injury showed bifrontal fracture with right frontal contusions. CT scan done at the time of present admission showed right frontal pneumocephalus probably secondary to fractured posterior wall of frontal sinus causing mass effect leading to subfalcine herniation. He underwent endoscopic frontal sinus obliteration using autogenic fat and fascial graft following which his hemiparesis improved significantly. Postoperative CT scan showed complete resolution of pneumocephalus and the mass effect. At the time of discharge he was independently ambulant [Figure 1].
Figure 1: The pneumocephalus is seen in right frontal lobe arising from fracture of posterior wall of frontal sinus (white arrow in a) and progressing further intracranially (b-d). (e) depicts intra-operative radiograph confirming frontal recess localisation during endoscopic procedure. (f-h) show CT scan done on post-operative day three, showing complete disappearance of pneumocephalus

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Appearance of delayed pneumocephalus was suggestive of persistent ingress of air. The significant and expanding volume of air was suggestive of uncompensated absorption by brain parenchyma. The presence of likely "Dandy's ball valve mechanism" was thought of, which was leading to progressive accumulation without a significant egress. [1] The fractured posterior wall of frontal sinus was probably acting as a conduit for air after each inhalation. Based on the assumptions we decided to break this vicious cycle by endoscopically sealing off the frontal sinus. As soon as the constant ingress of air stopped the entrapped air got absorbed thereby reducing the stretch on precentral motor fibers resulting in quick recovery of hemiparesis.

Various described methods of treating pneumocephalus range from simple twist drill or burr hole to craniotomies. [3] There was one report mentioning use of nasal endoscopic incision of pericranial graft to release tension pneumocephalus developed after anterior skull base surgery for esthesioneuroblastoma. [4] Most of these strategies are directed at providing new exit point of pneumocephalus. The present case is unique as it was treated with minimally invasive endoscopic method hitting the root cause of disease. It avoided the complications of extensive craniotomy. The endoscopic skull base surgeon always harbored the fear of post procedural pneumocephalus, however, the use of same tool for its treatment has not been described earlier. [2] The entire surgical science revolves around the philosophy of "treatment of the cause" and finding minimally invasive approaches for the same.

 
  References Top

1.Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 2013;4:37.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Martínez-Capoccioni G, Serramito-García R, Cabanas-Rodríguez E, García-Allut A, Martín-Martín C. Tension pneumocephalus as a result of endonasal surgery: An uncommon intracranial complication. Eur Arch Otorhinolaryngol 2013;271:1043-9.  Back to cited text no. 2
    
3.Kendre B, Deopujari C, Karmarkar V, Shah S. Frontal sinus osteoma with pneumocephalus and progressive hemiparesis. Neurol India 2013;61:694-5.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Krischek B, Vescan A, Zweifel C, Zadeh G, Gentili F. Endonasal endoscopic release of a delayed tension pneumocephalus after craniofacial resection of a tumor of the anterior skull base. J Neurol Surg A Cent Eur Neurosurg 2013;74:e271-4.  Back to cited text no. 4
    


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