An unusual presentation of dystonia and chorea from intraventricular pneumocephalus

Abstract

Background:Pneumocephalus is a common finding following intracranial procedures, typically asymptomatic and resolves within several days. However, in some cases, pneumocephalus presents with headache, encephalopathy, or symptoms of elevated intracranial pressure. Here, we present a case of iatrogenic tension pneumocephalus following endoscopic sinus surgery, presenting as abnormal involuntary movements resembling a movement disorder with choreiform movements.Case Description:A 67-year-old previously healthy male presented with new onset chorea and dystonia associated with headache, encephalopathy, and postural instability 4 days after undergoing endoscopic sinus surgery for chronic sinusitis and nasal polyps. Computed tomography showed prominent intraventricular pneumocephalus causing enlargement of the anterior horns of both lateral ventricles with lateral displacement of the basal ganglia nuclei and a bony defect in the skull base. Neurosurgical correction of the cranial defect provided complete symptomatic resolution. Pneumocephalus as a result of an iatrogenic injury of the skull base manifesting as an acute movement disorder is a rare complication of a nasal sinus procedure. We speculate that compression of the caudate nucleus and striatum resulted in decreased pallidothalamic inhibition and thalamocortical disinhibition leading to the development of a hyperkinetic movement disorder.Conclusion:This unusual presentation of a common procedure illustrates a neurological emergency that requires prompt recognition and timely correction.

Tension Pneumocephalus: A Rare Complication Following Skull Base Surgery

“…TP following skull base surgery is a rare complication, previously reported to have only been reported in 33 cases in the literature, [1][2][3]6,7,14,15,[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] including this case (Table 1). Iatrogenic injury has been reported as a cause of TP during skull base surgery.…”

“…Polster et al 33 Endoscopic sinus surgery Recovery Iqbal/ et al 34 Transphenoidal resection pituitary macroadenoma Recovery Biju et al 2 Bifrontal craniotomy and transnasal endoscopic surgery Recovery Castle-Kirszbaum et al 15 Endoscopic It is not possible to definitively determine the mechanism by which tension pneumocephalus developed in this patient. While it is likely that an inverted soda bottle mechanism contributed to this patient's presentation, it could also have been due to a flap-valve mechanism or a combination of the 2 as they are not mutually exclusive.…”

<p>Tension Pneumocephalus from Endoscopic Endonasal Surgery: A Case Series and Literature Review</p>

“…Eighteen articles were identified using the search strategy outlined above in the study design and literature review. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] The earliest report from this search was a single case report published in 1994. 3 Including the four cases from our institutions described above, a total of 26 cases were included in the review (Table 1) For the treatment of TP, endoscopic multilayer closure of the skull base defect was performed in 13 patients, cranial burr hole surgery in two, cranial burr hole surgery and endoscopic multilayer closure of the skull base defect in five, and bifrontal craniotomy to repair the defect in the skull base in two patients.…”