Tension Pneumocephalus: A Rare Complication of Transsphenoidal Resection of a Pituitary Macroadenoma

Abstract

Tension pneumocephalus (TP) is described as the presence of a large amount of air in the cranial cavity, compressing the parenchyma and ventricles. It is a rare neurosurgical emergency and has been reported in only a handful of cases as a complication of transsphenoidal resection of a pituitary adenoma. Our reported case is an addition to the series of those cases. A 60-year-old male patient underwent transsphenoidal resection of a pituitary macroadenoma. Computed tomography (CT) of the head performed post-procedure showed post-surgical changes with no identification of any acute intracerebral processes. On postoperative Day 2, the patient had a bout of sneezing and since that time, he was noted to be more altered in terms of his mentation and lethargic with no focal neurological deficits. A repeat CT of the head showed a large amount of air in the intracranial cavity compressing the brain parenchyma with slit-like appearances of the cerebral ventricles. The patient underwent emergent bifrontal air evacuation through burr holes. A cerebrospinal fluid leak was also noted while reconstructing the skull base. A postoperative CT scan showed marked resolution of TP. The patient improved clinically, was discharged home five days later, and was monitored closely by the surgical team on an outpatient basis.

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.…”

“…3 In addition, there are only a few studies in the literature describing the development of TP in patients who undergo endoscopic surgery for various reasons (chronic rhinosinusitis, nasal septum deviation, pituitary macroadenoma). [4][5][6] Accordingly, the present study collected data from all previously reported cases of TP caused by endoscopic endonasal surgery in the literature, as well as four additional cases treated by the authors, to collectively review the diagnosis, management, and treatment outcomes of this rare disease.…”

Tension pneumocephalus following cranioplasty with a titanium plate: a case report

“…The treatment methods used for pneumocephalus vary according to the mechanism and location. 6 , 12 , 13 , 16 The mainstay of conservative treatment is augmented oxygen delivery. 16 – 19 By breathing 100% oxygen, nitrogen washout from the lungs hastens, facilitating the diffusion of the nitrogen in the intracranial bubble into the circulating blood following its gradient.…”