Traumatic Subarachnoid-Pleural Fistula

Although traumatic pneumocephalus is not uncommon, it rarely evolves into tension pneumocephalus (TP). Characterized by the presence of increasing amounts of intracranial air and concurrent appearance or worsening neurological symptoms, TP can be devastating if not recognized and treated promptly. We present two cases of traumatic TP and a concise review of literature on this topic. Two cases of traumatic TP are presented. In addition, a literature search revealed 20 additional cases, of which 18 had sufficient information for inclusion. Literature cases were combined with the 2 reported cases and analyzed for demographics, mechanism of injury, symptoms, time to presentation (acute <72 h; delayed >72 h), diagnostic/treatment modalities, and outcomes. Twenty cases were analyzed (17 males, 3 females, median age 26, range 8–92 years). Presentation was acute in 13/20 and delayed in 7/20 patients. Injury mechanisms included motor vehicle collisions (6/20), assault/blunt trauma to the craniofacial area (5), falls (4), and motorcycle/ bicycle crashes (3). Common presentations included depressed mental status (10/20), cerebrospinal fluid rhinorrhea (9), headache (8), and loss of consciousness (6). Computed tomography (CT) was utilized in 19/20 patients. Common underlying injuries were frontal bone/sinus fracture (9/20) and ethmoid fracture (5). Intracranial hemorrhage was seen in 5/20 patients and brain contusions in 4/20 patients. Nonoperative management was utilized in 6/20 patients. Procedural approaches included craniotomy (11/20), emergency burr hole (4), endoscopy (2), and ventriculostomy (2). Most patients responded to initial treatment (19/20). One early and one delayed death were reported. Traumatic TP is rare, tends to be associated with severe craniofacial injuries, and can occur following both blunt and penetrating injury. Early recognition and high index of clinical suspicion are important. Appropriate treatment results in improvement in vast majority of cases. CT scan is the diagnostic modality of choice for TP.Republished with permission from:Pillai P, Sharma R, MacKenzie L, Reilly EF, Beery II PR, Papadimos TJ, Stawicki SPA. Traumatic tension pneumocephalus: Two cases and comprehensive review of literature. OPUS 12 Scientist 2010;4(1):6-11.

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“…Effective therapy of TP through a controlled decompression using a closed water-seal drainage system has also been described. [2728]…”

Section: Discussionmentioning

confidence: 99%

Traumatic tension pneumocephalus – Two cases and comprehensive review of literature

Pillai

Sharma

MacKenzie

et al. 2017

Int J Crit Illn Inj Sci

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“…The anatomic detail provided by CT myelography can aid in planning for surgical correction, but it carries a high false-negative rate [39, 40]. Nuclear cisternograms with infusion of 111 In-DTPA is more sensitive for detection of SPF [5, 41], though does not provide anatomic detail and must hence be combined with other imaging for preoperative planning.…”

Section: Discussionmentioning

confidence: 99%

Subarachnoid-Pleural Fistula: Applied Anatomy of the Thoracic Spinal Nerve Root

et al. 2011

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Subarachnoid-pleural fistula (SPF) is a rare complication of chest or spine operations for neoplastic disease. Concomitant dural and parietal pleural defects permit flow of cerebrospinal fluid into the pleural cavity or intrapleural air into the subarachnoid space. Dural injury recognized intraoperatively permits immediate repair, but unnoticed damage may cause postoperative pleural effusion, intracranial hypotension, meningitis, or pneumocephalus. We review two cases of SPF following surgical intervention for chest wall metastatic disease to motivate a detailed review of the anatomy of neural, osseous, and ligamentous structures at the intervertebral foramen. We further provide recommendations for avoidance and detection of such complication.

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“…Although CT myelography can provide a better anatomical picture, it may have an increased incidence of false-negative results. 10,15,19,[23][24][25] We recommend a nuclear study as the initial investigation because it is more sensitive, and this should be followed by CT myelography, if necessary, to define further the anatomical details of the fistula. As indicated in the aforedecribed case in which there was no objective evidence of an SPF despite symptoms and signs consistent with one, an objective study such as nuclear cisternography is important to verify the diagnosis before committing a patient to repeated operation.…”

Section: Discussionmentioning

confidence: 99%

Subarachnoid—pleural fistula after resection of thoracic tumors

Hentschel¹,

Rhines²,

Wong

et al. 2004

Journal of Neurosurgery: Spine

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Object. Little has been written about the appropriate diagnosis, investigation, and management of subarachnoid—pleural fistula (SPF). The authors report a series of patients with SPF that developed after resection of spinal tumor and discuss the diagnosis and treatment of this entity. Methods. Between 1993 and 2002, nine patients with SPF observed after spinal surgery at the M. D. Anderson Cancer Center were prospectively followed. In all patients the tumors were located in the thoracic region, and the most common entity was vertebral body metastasis (six cases), with renal cell carcinoma being the most common form of the disease (three cases). All but one patient underwent surgery via a transthoracic approach; in only one patient an intradural approach was performed. The most common presentation was overt cerebrospinal fluid (CSF) leakage, manifesting as chest tube drainage (four cases) or as leakage through the wound (one case). A definitive diagnosis of SPF was established in four patients, with evidence of extraspinal leakage on an 111In-radionuclide CSF study. Although all patients initially underwent a trial of lumbar CSF drainage, all but one required open repair, including creation of intercostal muscle (three cases) and omental (one case) flaps. Conclusions. After spinal surgery in which the thorax is entered, a diagnosis of SPF should be considered in any patient with abnormal chest tube output, persistent pleural effusion, or clinical evidence of intracranial hypotension. The diagnosis should be confirmed by performing a radionuclide-labeled CSF study. Definitive open repair is required in most cases and preferentially consists of a vascularized tissue graft, which is most easily obtained from an intercostal muscle flap.

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Traumatic Subarachnoid-Pleural Fistula

Cited by 26 publications

References 21 publications

Traumatic tension pneumocephalus – Two cases and comprehensive review of literature

Traumatic tension pneumocephalus – Two cases and comprehensive review of literature

Subarachnoid-Pleural Fistula: Applied Anatomy of the Thoracic Spinal Nerve Root

Subarachnoid—pleural fistula after resection of thoracic tumors

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