Elsevier

World Neurosurgery

Volume 114, June 2018, Pages 317-322
World Neurosurgery

Case Report
Spontaneous Intraventricular Tension Pneumocephalus: Case Report and Review of the Literature

https://doi.org/10.1016/j.wneu.2018.03.076Get rights and content

Highlights

  • A temporal bone defect with an encephalocele produces intradural pneumocephalus.

  • A ball-valve mechanism possibly led to tension intraventricular pneumocephalus.

  • Tension intraventricular pneumocephalus may lead to a comatose state.

  • An external ventricular drain may treat tension intraventricular pneumocephalus.

Background

Intracranial pneumocephalus is a well-known clinical entity most frequently caused by trauma and intracranial surgery. A less frequent cause of intracranial pneumocephalus is spontaneous pneumocephalus. Spontaneous pneumocephalus can have an intraventricular extension, causing tension intraventricular pneumocephalus.

Case Description

We present an exceptionally rare case of spontaneous otogenic intraventricular pneumocephalus in a 58-year-old female that resulted in a decline in mentation and neurologic deficit. The patient was subsequently treated with ventriculostomy and middle fossa craniotomy, with repair of a bony defect and dural closure.

Conclusions

This case demonstrates an unusual presentation of spontaneous intraventricular tension pneumocephalus necessitating ventriculostomy in addition to the traditional repair of a cerebrospinal fluid fistula.

Introduction

Pneumocephalus is a well-defined anomaly first was described in 1741 by Lecat. Spontaneous pneumocephalus (meaning in the absence of trauma, disease process, or iatrogenic intervention) was first described in 1954 by Jelsma and Moore.1 Markham2 further characterized spontaneous pneumocephalus in 1967, examining 295 cases of pneumocephalus and characterizing only 0.6% as spontaneous. Case reports of spontaneous otogenic pneumocephalus have been published.3, 4 Since 1967, there have been case reports describing spontaneous otogenic intraventricular pneumocephalus3 and describing spontaneous otogenic tension pneumocephalus,5 but to our knowledge, there has been only 1 previously reported case of a spontaneous otogenic intraventricular tension pneumocephalus.6 Tension pneumocephalus is a neurosurgical emergency that is caused by an accumulation of air resulting in increased intracranial pressures, which produces a myriad of clinical presentations, including restlessness, deteriorating consciousness, coma, and focal neurologic deficits.

Here we report a very rare case of patient who developed a spontaneous otogenic intraventricular tension pneumocephalus necessitating an emergent craniotomy for encephalocele repair and ventriculostomy.

Section snippets

Case Presentation

A 58-year-old African American female presented with a headache of 1 week's duration and voluminous rhinorrhea the day before presenting to the hospital. She reported no history of intracranial surgery, obstructive sleep apnea, trauma, infection, meningitis, scuba diving, or exceptional Valsalva maneuvers. A head computed tomography (CT) scan demonstrated extensive pneumocephalus with significant intraventricular involvement (Figure 1) and signs of mobile communication between the sphenoid

Discussion

Markham has described 2 theories regarding the pathophysiology of pneumocephalus.7 One theory is the ball-valve effect, which describes air being forced through the craniodural defect from coughing or nose blowing. The other theory is the inverted bottle effect, when there is dural defect with subsequent CSF leakage. CSF flowing out of the cranium results in a slight decrease in intracranial pressure, so air enters the cranium to equalize pressures. Spontaneous pneumocephalus is defined as an

Conclusions

Spontaneous otogenic pneumocephalus is a rarely described phenomena that usually results from a temporal bone defect. This defect permits air to communicate to the intracranial space. The presence of a dural defect allows air to communicate intradurally. Spontaneous intradural pneumocephalus is a rarely described entity that can be exacerbated by a ball-valve effect that can trap air, resulting in increased intracranial pressure. The treatment of choice for this is evacuation of the air,

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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