Jolurnal of Neurology, Neuirosurgery, anid Psychiatry, 1974, 37, 271-274

Pneumocephalus: an unusual cause

RICHARD D'ADDARIO, JACK GREENBERG,' THOMAS J. E. O'NEILL,AND PASCHAL SPAGNA

From the Departments of Neurology and Thoracic Surger*y, Episcopal Hospitaland Temple University, Philadelphia, Pennsylvania, U.S.A.

SYNOPSIS A 60 year old male had an open thoracotomy for bronchogenic carcinoma. On thetwelfth hospital day he became obtunded and complained of headache. Radiographs revealed intra-cranial air. It was thought that the pneumocephalus in this patient was most likely secondary to atension pneumothorax continuously forcing air through a dural tear sustained at the time of initialsurgery. The causes of pneumocephalus are reviewed and no similar case report has been found in theliterature.

Cranial aerocoele (pneumocephalus) was firstfully described by Chiari (1844). Markham(1967), in a thorough review of the literature,listed the various causes as follows: trauma (frac-tures of the skull involving either the sinuses orbase), 73.900; neoplasm, 12 9'/; infection, 8,8%;1 Address for reprints: Dr. Jack 0. Greenberg, Episcopal Hospital,Front St. and Lehigh Ave., Philadelphia, Pennsylvania 19125, U.S.A.

surgical intervention, 3-700; and idiopathic,066%. He reviewed a total of 295 cases from 1884to 1967. Postoperative pneumocephalus has beenlargely secondary to sinus surgery or intra-cranial procedures. Kessler and Stern (1962) re-ported a case that occurred after ventriculo-pleural shunt for hydrocephalus with develop-ment of a bronchoventricular fistula. Taverner

FIG. 1. Anteroposterior radiograph of the skull FIG. 2. Lateral radiograph of the skull(4 December 1970) (4 December 1970)

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Richard D'Addario, Jack Greenberg, Thomas J. E. O'Neill, and Paschal Spagna

and Phillips (1947) described a somewhat similarcase in a soldier during the Second World Warin which a bullet entered the thoracic cavity,ascended subcutaneously, and finally lodged inthe posterior fossa.The present case represents what appears to be

the first report of pneumocephalus after a purelythoracic surgical procedure.

CASE HISTORY

A 60 year old white male was admitted to theEpiscopal Hospital on 17 November 1970, becauseof severe rib pain. A diagnosis of bronchogeniccarcinoma had been made by open thoracotomy inMay 1970. The carcinoma had been unresectable andthe patient subsequently received a course of radia-tion therapy. There was no evidence at that time ofdistant metastasis. There was no history of past headtrauma, cerebrospinal fluid rhinorrhoea, or sinusdisease.

Physical examination revealed normal vital signsin a cachectic white male. The patient was alert andin moderate distress secondary to the rib pain. Posi-tive findings were limited to decreased breath soundsand dullness to percussion over the right side of thechest. The neurological examination was normal.

Because of the intractable pain, the patient under-

went open thoracotomy on 19 November. Thetumour was found to be localized to the right upperlobe and closely adherent to ribs 1-6. These were re-moved along with the transverse processes of the 1stto 6th thoracic vertebrae. A small cerebrospinalfluid leak was noted upon removal of the transverseprocesses. The pathological diagnosis was mixedbronchogenic carcinoma.

Postoperatively, the patient developed a transitoryrise in temperature but remained alert. There wasserosanguineous drainage from the chest tubes untilthe fifth day when an air leak was demonstratedradiologically with a 20% pneumothorax. This re-solved and the chest tubes were removed. On thetwelth day the patient was noted to be obtunded andcomplained of headache. Radiographs of the chestagain revealed a right pneumothorax which wasreduced by tube thoracotomy. Because of persistentcomplaints of headache, a radiograph of the skullwas obtained which revealed intracranial air (Figs Iand 2). The patient continued to be intermittentlyobtunded without focal neurological signs. Drainagefrom the chest tubes after three days was clear andwatery.The patient subsequently developed a temperature

of 38 90 C (1020 F) with thickened pulmonary secre-tions, and was started on antibiotics. A repeat radio-graph of the skull on 24 December showed a signifi-cant increase in the intracraniai air (Figs 3 and 4),

FIG. 3. Anteroposterior radiograph of the skull FIG. 4. Lateral radiograph of the skull(24 December 1970) (24 Decenmber 1970)

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Pneumocephalus: an unusual cause

FIG. 5. Coronal section of brain through temporal tips

despite improvement in the pneumothorax. An EEGrevealed diffuse slowing with 6-7 Hz theta and 1-3Hz delta activity. He followed a rapidly deterioratingcourse and died on 28 December, 30 days post-operatively. Neurological examination one day beforehis death revealed him to be stuporous with a rightHorner's syndrome and slight increase in the deeptendon reflexes on the right. Funduscopic examina-tion was normal.At necropsy, subcutaneous emphysema was noted

on the lower neck, supraclavicular space and upperchest on the right. There was no fluid in the thoraciccavity and both lungs revealed bronchopneumonia.Examination of the brain revealed moderate oedemaand mild dilatation of the ventricles (Fig. 5). Multiplesections revealed only a small area of haemorrhagein the left frontal lobe adjacent to the cingulategyrus measuring 1 x 0 5 cm. Microscopic examina-tion of the brain of this area was consistent with ahaemorrhagic infarct of relatively recent onset. Theremainder of the histopathology was negative.

COMMENT The pneumocephalus in this patient

was most probably secondary to the tensionpneumothorax that was continuously forcing airthrough a dural tear sustained at the time ofinitial surgery and not allowing absorption totake place. One can only speculate on the roleplayed by the pneumocephalus in his death.There was no evidence of tentorial or cerebellarherniation, nor were there signs of infectionintracranially. The pneumocephalus may havecontributed to his decreased level of alertness,and this, coupled with the usual postoperativesplinting of chest surgery, made him a primecandidate for a pulmonary infection.We would therefore suggest that any patient

developing persistent headaches after majorthoracic procedures involving the posterior ribsis a suspect for cerebrospinal fluid leak througha traumatized dura mater. If pneumothorax ispresent, radiographs of the skull should be ob-tained to rule out intracranial air.One method of demonstrating a cerebrospinal

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Richard D'Addario, Jack Greenberg, Thomas J. E. O'Neill, and Paschal Spagna

fluid leak would be to inject a dye, such as

fluorescein, into the lumbar subarachnoid spacewith subsequent observation of the chest tubedrainage. This was planned but the patient diedbefore it could be accomplished. Therapy, as

originally suggested by Dandy (1926), should bedirected towards surgical closure of the fistula or

leak. Interestingly, traumatic pneumocephalusgave Dandy the idea of carrying out pneumo-encephalograms.

In the experience of one of the authors (T.J.O.),while performing many hundreds of radicalthoracoplasties for tuberculosis requiring com-

plete resection of transverse processes ofvertebrae, it was common to observe leakage ofcerebrospinal fluid at the site of emergence of theintercostal nerves. In none of these cases was

there any syndrome similar to the one presentedhere, although routine radiographs of the skullwere not performed. Routine radiographs of theskull are planned for future operations of thisnature.

REFERENCES

Chiari, H. (1884). Ueber einen Fall von Luftansammiung inden Ventrikeln des menschlichen Gehirns. 7eitschrift JiirHeilkunde, 5, 383-391.

Dandy, W. E. (1926). Pneumocephalus (intracranial pneuma-tocele or aerocele). Archives of Surgery, 12, 949-982.

Kessler, L., and Stern, W. Z. (1962). The ventriculopleurashunt procedure for hydrocephalus. Joutrnal of Pediatrics,60, 418-420.

Markham, J. W. (1967). The clinical features of pneumo-cephalus based upon a survey of 284 cases with a report of11 additional cases. Acta Neurochirurgica, 16, 1-78.

Taverner, D., and Phillips, G. (1947). Pneumocephalusfollowing a penetrating wound of the chest. British Journalof Surgery, War Suppl. No. 1, pp. 262-265.

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