Acute, life-threatening postoperative pneumocephalus: emergency diagnostic and therapeutic steps with underlying pathophysiology

Editor—Pneumocephalus, defined as ‘air trapped inside the intracranial vault’, 1 Siegel J.L. Hampton K. Rabinstein A.A. McLaughlin D. Diaz-Gomez J.L. Oxygen therapy with high-flow nasal cannula as an effective treatment for perioperative pneumocephalus: case illustrations and pathophysiological review. Neurocrit Care. 2018; 29: 366-373 Crossref PubMed Scopus (22) Google Scholar is a common and typically asymptomatic finding after neurosurgical procedures that resolves spontaneously, and is seen in 77–100% of patients on postoperative scans. 2 Toung T.J. McPherson R.W. Ahn H. Donham R.T. Alano J. Long D. Pneumocephalus: effects of patient position on the incidence and location of aerocele after posterior fossa and upper cervical cord surgery. Anesth Analg. 1986; 65: 65-70 Crossref PubMed Google Scholar ,3 Dexter F. Reasoner D.K. Theoretical assessment of normobaric oxygen therapy to treat pneumocephalus. Anesthesiology. 1996; 84: 442-447 Crossref PubMed Scopus (45) Google Scholar Additional aetiologies include head trauma with dural tear, 4 Schirmer C.M. Heilman C.B. Bhardwaj A. Pneumocephalus: case illustrations and review. Neurocrit Care. 2010; 13: 152-158 Crossref PubMed Scopus (130) Google Scholar lumbar puncture, and spinal anaesthesia. A critical form of pneumocephalus is tension pneumocephalus, defined as increasingly enlarging one-way air entry into the cranium, secondary to positive pressure ventilation or increased intra-abdominal pressure. 1 Siegel J.L. Hampton K. Rabinstein A.A. McLaughlin D. Diaz-Gomez J.L. Oxygen therapy with high-flow nasal cannula as an effective treatment for perioperative pneumocephalus: case illustrations and pathophysiological review. Neurocrit Care. 2018; 29: 366-373 Crossref PubMed Scopus (22) Google Scholar Tension pneumocephalus is suspected from non-specific but critical semiology, including headache, decreasing level of consciousness, cranial nerve palsy, or hemiparesis. 4 Schirmer C.M. Heilman C.B. Bhardwaj A. Pneumocephalus: case illustrations and review. Neurocrit Care. 2010; 13: 152-158 Crossref PubMed Scopus (130) Google Scholar