LETTER TO EDITOR Year : 2023  |  Volume : 71  |  Issue : 5  |  Page : 1082-1083

Delayed Tension Pneumocephalus Following Traumatic Brain Injury: A Rare Entity

Nandakumar Poonthottam1, Ramkumar Menon2
1 General Practitioner, Thrissur, Kerala, India
2 Atreya Hospital, Thrissur, Kerala, India

Date of Submission21-Aug-2023Date of Decision27-Aug-2023Date of Acceptance27-Aug-2023Date of Web Publication18-Oct-2023

Correspondence Address:
Nandakumar Poonthottam
Mangalam, Malappuram, Kerala, 676 561
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0028-3886.388070

How to cite this article:
Poonthottam N, Menon R. Delayed Tension Pneumocephalus Following Traumatic Brain Injury: A Rare Entity. Neurol India 2023;71:1082-3

Sir,

Delayed tension pneumocephalus is characterized by a continuous buildup of air within the cranial cavity over more than 72 h, leading to abnormal pressure exerted on the brain and subsequent neurologic deterioration.[1],[2] The authors are reporting a unique case of delayed tension pneumocephalus following a remote head injury.

A 23-year-old male patient presented with a chief complaint of left-sided weakness that had been progressively worsening over 1 month. The patient had a history of head injury 3 months ago, for which he received treatment at a local hospital. He was conscious, alert, and oriented with the Glasgow coma scale (GCS) of 15/15. His computed tomography (CT) at that time revealed evidence of bilateral basifrontal contusions and fracture of frontal and nasal bones. He was managed conservatively and discharged subsequently.

He presented in our neurosurgical outpatient with a history of left hemiparesis. On examination, the patient was conscious and oriented and had a GCS score of 15/15. Neurological examination showed power in the left upper and lower limb grade 4/5 of the Medical Research Council (MRC), left hyporeflexia, and ataxic gait. Power in the right upper and lower limbs was found to be 5/5 of MRC. Pupils were bilaterally equal and reactive to light, cranial nerves were within normal limits, sensations were intact, and no meningeal signs were observed.

A computed tomography (CT) scan of the brain demonstrated a large pneumocephalus in the right frontal region, causing a mass effect on the surrounding neuroparenchyma [Figure 1]. Multiple fractures involving the frontal sinus were observed bilaterally. The fracture on the right side specifically involved the posterior table of the frontal sinus, creating a communication pathway with the pneumocephalus [Figure 2]. Consequently, the patient underwent a right frontal craniotomy for the repair of the frontal sinus under general anesthesia. The sinus was exteriorized using a galeal flap. The procedure was uneventful, the patient received treatment with antiepileptics, antibiotics, anti-edematous agents, and other supportive measures.

Figure 1: Large pneumocephalus on the right frontal region, causing mass effect on the surrounding neuroparenchyma

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Figure 2: Sagittal CT bone window showing communication between frontal sinus and pneumocephalus extending posteriorly and superiorly

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A follow-up CT scan was taken 3 days after the surgery, which revealed a significant decrease in the size of the pneumocephalus and resolution of the mass effect on the adjacent brain tissue [Figure 3]. Moreover, the communication between the pneumocephalus and the right frontal sinus was no longer evident. CT scan is the most effective method for diagnosing pneumocephalus, as it can detect even small amounts of air as low as 0.5 mL.[2],[3] Last follow-up of the patient was 5 months post-surgery and he continues to remain asymptomatic.

Figure 3: Significant decrease in the size of the pneumocephalus and resolution of the mass effect on the adjacent brain tissue

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Pillai P, Sharma R, MacKenzie L, Reilly EF, Beery PR 2nd, Papadimos TJ, et al. Traumatic tension pneumocephalus - Two cases and comprehensive review of literature. Int J Crit Illn Inj Sci 2017;7:58-64.  
[PUBMED]  [Full text]  2.Kankane VK, Jaiswal G, Gupta TK. Posttraumatic delayed tension pneumocephalus: Rare case with review of literature. Asian J Neurosurg 2016;11:343-7.  
[PUBMED]  [Full text]  3.Rao V, Fredriksli O, Gulati S. Post-traumatic epidural tension pneumocephalus: A case report. J Med Case Rep 2015;9:151.  
    
  [Figure 1], [Figure 2], [Figure 3]