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Table of Contents    
NEUROIMAGE
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1635-1636

A Stitch in Time Saves Nine: Delayed Presentation of Tension Pneumocephalus as Stroke


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission22-Apr-2021
Date of Decision05-Oct-2021
Date of Acceptance11-Oct-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Kokkula Praneeth
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333488

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How to cite this article:
Praneeth K, Nachiappan DS, Gupta D. A Stitch in Time Saves Nine: Delayed Presentation of Tension Pneumocephalus as Stroke. Neurol India 2021;69:1635-6

How to cite this URL:
Praneeth K, Nachiappan DS, Gupta D. A Stitch in Time Saves Nine: Delayed Presentation of Tension Pneumocephalus as Stroke. Neurol India [serial online] 2021 [cited 2022 Jan 28];69:1635-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1635/333488




A 51-year-old man with a history of a fall from a height 12 days earlier, treated at another hospital, presented now with a sudden onset loss of consciousness. The Computed Tomography (CT) of the head revealed tension pneumocephalus (TPC) [[Figure 1], Panel A]. An emergency twist-drill craniostomy released a puff of air and a subdural drain was placed with an underwater seal.[1],[2] On enquiring, the patient had a history of right-sided Cerebrospinal Fluid (CSF) otorrhea for the previous three days.[2] CT at the time of the fall showed a right parietal thin Extradural Hematoma (EDH), left frontal and temporal contusions, right temporal bone fracture, and there was no evidence of pneumocephalus. An Magnetic resonance imaging (MRI) performed 36 h post-admission revealed left posterior cerebral artery territory infarct with hemorrhagic conversion [[Figure 1], Panel B and C] and MR cisternogram revealed no active CSF leak. He gradually regained consciousness after 48 h of admission. The subdural catheter drained CSF for 3 days and there was a resolution of pneumocephalus and CSF otorrhea [[Figure 1], Panel D] Delayed post-traumatic CSF otorrhea can be a potential cause of TPC, which can present as a stroke. Tension pneumocephalus is a very rare cause of ischemic infarct.[3] This is the second case of TPC in the literature presenting with stroke, while in another case, TPC developed following endoscopic sinus surgery.[3] Raised intracranial pressure due to the pneumocephalus can result in trans-tentorial herniation leading to an infarct. An early evaluation and appropriate intervention are warranted to bail out of this life-threatening emergency.
Figure 1: Panel A - NCCT at admission showing tension pneumocephalus with “Mount Fuji” sign. Panel B and C - MRI T2 FLAIR and SWI images (36 hrs post-admission) revealing left posterior cerebral artery territory infarct with hemorrhagic conversion (hyperintensity on FLAIR and blooming on SWI) and resolving left frontotemporal contusions. Panel D - NCCT Head (Day4 post-admission) demonstrating resolution of pneumocephalus

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Harvey JJ, Harvey SC, Belli A. Tension pneumocephalus: The neurosurgical emergency equivalent of tension pneumothorax. BJR Case Rep 2016;2:20150127.  Back to cited text no. 1
    
2.
Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 2013;4:37.  Back to cited text no. 2
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3.
Cancelliere A. Nothing to sneeze at: Tension pneumocephalus causing an acute stroke following endoscopic sinus surgery. J Emerg Crit Care Med 2019;3:16.  Back to cited text no. 3
    


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